Using a better understanding of motivation to encourage and help smokers to stop

1. Using a better understanding of motivation to encourage and help smokers to stop Robert West University College London February 2007

2. But first a quiz For each statement just state whether it is ‘True’ or ‘False’ or leave it blank if you do not know

3. Smoking and Health • Stopping smoking at age 40 increases life expectancy by about 9 years • Stopping smoking at age 60 increases life expectancy by 1 year • Smoking has been found to increase risk of stroke

4. Smoking and health • Smokers are more likely to suffer from pre-eclampsia (dangerously high blood pressure during pregnancy) than non-smokers • Resting blood pressure typically goes down when people stop smoking • The weight gain that many smokers experience when they stop usually lasts less than a year

5. Clinical issues • The nicotine withdrawal symptom, irritability, usually last about 8 weeks • Brief opportunistic advice from a GP leads about 5% of smokers to stop for at least 6 months • Acute forms of nicotine delivery such as gum, lozenge and nasal spray have been found to reduce urges to smoke but nicotine patches have not

6. Clinical issues • The threshold for expired-air carbon monoxide concentration to detect smoking is usually set at 3+ ppm • Clinical trials have found that face-to-face counselling helps an average of 10% of smokers to stop for at least 6 months • Trials of nicotine patches for smoking cessation have been found to increase 12-month continuous abstinence rates by 5-7% compared with placebo

7. Pharmacology • The plasma half life of nicotine is typically less than 3 hours • Nicotine binds with greater affinity to the alpha4-beta2 NAch receptor than the alpha7 receptor • Smokers typically ingest between 1.0 and 1.5mg of nicotine per cigarette

8. Some questions about smoking and motivation • Should you ask a smoker if s/he wants to stop before offering help and support? • Should you advise a smoker who wants to stop to wait so they can plan ahead or allow them to stop now if they feel ready? • Should you encourage smokers to list the pros and cons of smoking to help motivate them to stop? • If a smoker has previously said they are not interested in stopping, should you raise the topic of smoking with them on another occasion? • What is the best advice you can give someone about what to do when they are tempted to smoke? • What is the best advice you can give to someone who has smoked a cigarette at a party after the quit date? • What is the single most important mental change when it comes to becoming an ex-smoker?

9. Outline • What do we mean by ‘motivation’? • What has to go into a model of motivation? • Constructing a more complete model of motivation: PRIME Theory • Applying PRIME theory to smoking

10. 1. What is motivation

11. Motivation • Motivation is: • what energises and directs our behaviour • given what we are capable of and have the opportunity to do, it determines what we do and don’t do – and when! Behaviour Motivation Capability Opportunity

12. 2. What are the ingredients of a theory of motivation?

13. Why did he do that? • He had planned to do it • He thought it was the right thing to do • He wanted to do it • He needed to do it • He did it without thinking

14. Plans • Our lives are governed by plans • diaries • resolutions • intentions • But we often ... • abandon them • put them off • forget them • ignore them • suspend them

15. Choice and decision making • We ... • envision a goal • are presented with an opportunity • are presented with a problem • If • we remember or are told ‘what to do’ we do it • Otherwise • we try to work out what to do

16. Working out what to do • If • we envision there being a ‘right answer’ we try to calculate it using one or more methods that we think apply • Otherwise • we weigh up the pros and cons as best we can

17. Weighing up the pros and cons • We investigate various courses of action and features that make them more or less attractive • We revise our list of options and/or our evaluations of these options until we: • reach a satisfactory solution • believe we have worked out least bad of the unsatisfactory solutions • run out of time • get distracted • lose interest • give up

18. The role of feelings • Feelings are experiences ranging from pleasure and pain, through hunger and thirst to happiness and sadness • They influence our choices by: • making things attractive or unattractive • influencing the way we think about the options • They influence our automatic reactions by: • acting as a stimulus • influencing the way that we react to other stimuli

19. Different types of feeling • Physical feelings • e.g. pain, physical discomfort, sensory pleasure • Drives • e.g. hunger, thirst • Generalised emotions • e.g. anxiety, depression, happiness, curiosity, excitement, amusement, uplifted, awe-struck, disgust • Targeted emotions • e.g. liking, disliking • Motives • e.g. wants, needs, desires, urges

20. Willpower and self-control • We experience conflict between what we ‘should’ do and what we feel impelled to so or want to do • People show willpower or exercise self-control when they do what they believe they should do in the face of impulses, desires and needs to do something else

21. Our sense of self • As we grow up and through adulthood we form images and beliefs about ourselves as we think we are and as we could be • These generate feelings ...

22. Incentives • Economic • money! • Moral/social • respect, approval, self-respect etc. • Personal • pleasure, pain, comfort, satisfaction etc.

23. ‘Automatic’ responses • We encounter a situation or a stimulus and respond without thinking • We experience an impulse to act in a particular way and just do it

24. Where do motivations come from? • Instinct • we are hard-wired to react in particular ways • Habit • repetition of a behaviour leads to it becoming ingrained • Association • we come to experience feelings about things because they are associated with other things • Memory • we remember past experiences • Analysis • we apply our own version of logic and reasoning to ideas • Communication • other people tell us what is good or bad etc. • Imitation • we copy what we observe in others

25. 3. Constructing a synthetic theory

26. The starting point for a synthetic model Humans are more or less instinctive, habit-driven, emotional decision-makers with a propensity to make and break plans, powerfully influenced by our social world, with a sense of identity which can act as a source of self-control

27. Responses • Responses involve starting, stopping or changing an action sequence • At each moment they are generated by the strongest of one or more competing impulses and inhibitory forces present at that moment Responses Impulses versus inhibitory forces

28. Impulses • Impulses can be generated by • Triggers interacting with innate dispositions (instincts) and learned dispositions (habits) • ‘Motives’: feelings of desire (anticipated pleasure or satisfaction) and/or need (anticipated relief from unpleasantness or tension) • They decay quickly unless refreshed Responses Impulses versus inhibitory forces Triggers Motives

29. Motives • Motives can be generated by: • Reminders interacting with the level internal tension at the time • ‘Evaluations’: beliefs about what is good/bad, right/wrong, useful/detrimental etc. Responses Impulses versus inhibitory forces Triggers Motives Reminders Evaluations

30. Evaluations • Evaluations are generated by: • Recall of observations • Analysis, inference • Accepting what others say • Motives • Plans Responses Impulses versus inhibitory forces Triggers Motives Reminders Evaluations Plans

31. Plans • Plans are ‘mental actions’ generated when: • Actions are considered to be required in the future • Actions are considered to be more likely to meet desires or needs if undertaken at a future time • Actions meeting desires or needs do have a sufficient priority to be enacted at the moment Responses Impulses versus inhibitory forces Triggers Motives Reminders Evaluations Plans

32. The human motivational system Plans (intentions) Evaluations (beliefs) External environment (stimuli, information) Internal environment (percepts, drives, emotional states, arousal, ideas, frame of mind) Motives (wants etc.) Internal stimulation Impulses (urges etc.) External stimulation Responses Flow of influence through the system

33. How the system runs • The system has an ‘energy level’ (arousal) that drives and influences the interactions between its elements • Motivation can be regarded as the shaping and direction of the propensity to act driven by the energy level

34. The importance of ‘the moment’ • Everything we think, feel or do is a reaction to what happened just prior to that acting on our dispositions • We only think about things when we are prompted to do so • The way that we think or feel about things depends to some degree on the current circumstances • Not thinking about things is an important ‘action’ subject to wants and needs (e.g. the need for relief from anxiety) Evaluations, wants, needs, impulses and plans only exist when triggered and otherwise have no influence

35. Dispositions • Attributes of the motivational system at a given time that cause it to react in a particular way to particular events Stimuli Internal and externally generated Dispositions Psychological and physiological Reactions Responses, impulses/inhibitions, motives etc. Time

36. The origin and development of dispositions Genetic endowment • Habituation/sensitisation - becoming less or more sensitive to repeated or ongoing stimuli • Associative learning- habit formation, classical conditioning • Explicit memory- images and thoughts recreated in response to cues Dispositions Time Experience

37. The dispositional landscape A model of disposition-environment interaction Environmental forces Critical periods: small environmental forces send the individual down different paths Deep chreods: small forces will not lead to lasting change; the system will settle back once they are removed; but if the system is on a cusp a small force will tip it into a new path From Waddington ‘Tools for Thought’

38. Identity • People differ in the propensity to think about themselves, the nature of the thoughts and feelings that they have, and how consistent and coherent these are • Identity is a very important source of motives; it is the foundation of personal norms that shape and set boundaries on our behaviour Identity refers to a disposition to generate particular thoughts and feelings about ourselves

39. Self-control • Self-control is a cornerstone of behaviour change. The moment-to-moment wants and needs arising from that must be strong enough to overcome impulses, wants and needs coming from other sources • The exercise of self-control is effortful; it requires and uses up mental energy Self-control refers to wants and needs that stem from evaluations arising from our identity

40. 4. Applying PRIME theory to smoking

41. The process of stopping smoking as identity change I smoke ... ... and I am happy about my smoking I am not even thinking about giving up I will give up some time ... but I am not happy about my smoking I have made plans to give up I do not smoke ... I am trying to give up smoking I am giving up smoking I have given up smoking but not completely I have given up smoking completely

42. While smoking ...

43. Motivation to stop smoking Quit attempt Habit/instinct Impulse to make a quit attempt Cues/triggers Choice Anticipated self-respect Desire to stop smoking Need to stop smoking Fear of ill-health/death Disgust, annoyance with smoking Felt stigma Anticipated praise Reminders Positive evaluations of stopping smoking Non-smoker ‘identity’ Beliefs about benefits of stopping smoking Only the flow of influence towards responses are shown

44. Motivation not to stop smoking Not making attempt Habit/instinct Inhibition of making a quit attempt Cues/triggers Choice Anticipated enjoyment of smoking Desire not to make attempt Need not to make attempt Anticipated loss of benefits Fears of failure Anticipated effort Anticipated benefits of smoking Negative evaluations of making attempt Reminders Beliefs about likelihood of failure Smoker ‘identity’ Only the flow of influence towards responses are shown

45. While not smoking

46. Motivation to smoke Smoking Habit/instinct Impulse to smoke Cues/triggers Choice Anticipated enjoyment Desire to smoke Need to smoke Nicotine ‘hunger’ Unpleasant mood and physical symptoms Anticipated benefit Reminders Positive evaluation of smoking Smoker ‘identity’ Beliefs about benefits of smoking Only the flow of influence towards responses are shown

47. Inhibition of smoking Not smoking Habit/instinct Inhibition Cues/triggers Choice Anticipated praise Desire not to smoke Need not to smoke Anticipated disgust, guilt or shame Fears about health Anticipated self-respect Negative evaluation of smoking Reminders Beliefs about benefits of not smoking Non-smoker ‘identity’ Plan not to smoke Only the flow of influence towards responses are shown

48. Creating the decision to stop • Generate motivational tension by: • frequent or persistent, high levels of want and need to make the change now accompanied by moderate to high levels of arousal • hope that the attempt to change will be successful • Trigger impulses to make the change attempt by: • repeated calls to immediate action • modelling the behaviour

49. Opening lines • When was the last time you tried to stop smoking? • How long did it last? • What did you use to help? • What led you to back to smoking? • It’s always worth having another go and there are lots of options to suit individual smokers which have been proved to help in research. Would you like to discuss these?

50. Supporting the decision to stop • Reduce the frequency and intensity of impulses, needs and wants to revert • Identify the sources of impulses and motives • Develop a specific plan in each case to avoid, escape or minimise these • Generate a strong commitment to a new identity with clear boundaries • Foster the ‘complete non smoker’ identity (smoking is not even an option, re-evaluation of place of smoking in their life) • Deal with lapses by re-asserting the new identity • ‘One day at a time’ • Maximise both intrinsic and extrinsic motives for not smoking (e.g. avoiding shame, gaining self-respect)