Evidence-based tobacco control: from molecule to policy

1. Evidence-based tobacco control: from molecule to policy Robert West University College London November 2011

2. Statement of competing interests • I undertake research and consultancy for companies that develop and manufacture smoking cessation medications • I have a share of a patent in a novel nicotine delivery device • I am co-director of the NHS Centre for Smoking Cessation and Training • I am a trustee of QUIT and on the scientific advisory board of Free & Clear

3. Topics • What is tobacco control? • The MPOWER approach • The COM-B model of behaviour • The Behaviour Change Wheel as a system for developing an intervention strategy • Applying COM-B and the BCW to tobacco control

4. Goals of tobacco control

5. MPOWER • Monitor tobacco use and prevention policies • Protect people from tobacco smoke • Offer help to quit tobacco use • Warn about the dangers of tobacco • Enforce bans on tobacco advertising, promotion and sponsorship • Raise taxes on tobacco A useful heuristic: need guidance on implementation

6. Tobacco control as ‘behaviour change’ • Tobacco use is a form of behaviour • The goal is to achieve sustained ‘behaviour change’ • prevention of tobacco uptake • tobacco cessation • changes in use of tobacco products • Models of behaviour change should provide a scientific basis for developing intervention strategies

7. Why theories are important • One can build a simple bridge on the basis of what seems intuitively sensible (an implicit commonsense model) and trial and error • But to build increasingly better bridges spanning longer distances and carrying heavier loads one needs an incremental technology based on theory

8. Theories of behaviour change • There is a rich body of theory in behaviour change. For example ... • Decision theory • how people assess risk and make choices • Learning theory • how experiences of reward and punishment control ourbehaviour • Personality theory • How people differ and why • Economic theory • how changes in price and availability affect behaviour • Social theory • how members of groups interact • Neurobiological theories • brain mechanisms underlying change

9. Models to be considered • COM-B model of behaviour in context • an overarching model of behaviour and what is needed to achieve behaviour change • PRIME Theory of motivation • a theory of motivation with particular emphasis on developing behaviour change interventions • The Behaviour Change Wheel • a system for developing theory- and evidence-based behaviour change interventions from COM-B and PRIME

10. Why these models? • They • bring together core components of other theories into a single coherent model • stay as close as possible to everyday language • are specifically aimed at developing behaviour change interventions Key references: Michie S, M van Stralan, West R(2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42. West R (2011) Models of Addiction. Lisbon: EMCDDA

11. Not a replacement for specific theories • A skeleton on which to put the flesh of specific theories so that they work together Learning theory Neurobiological theories Decision theory Personality theory Economic theories Social theories

12. COM-B system for analysing behaviour in context • Capability, motivation and opportunity all need to be present for a behaviour to occur • They all interact as part of a system • Motivation must be stronger for the target behaviour than competing behaviours

13. Capability • The person has to be physically and psychologically able to perform the behaviour • Psychological capability • knowledge and understanding of • why it could be worth doing it • how to do it • capacity and skills for self-regulation • impulse control • mental energy • how to make effective plans • how to structure the environment

14. Motivation • The person has to want or need to engage in the behaviour at relevant moments more than they want to do something else or not do it • Sources of motivation • Reflective thought • Evaluation of costs and benefits • Self-conscious plans • Feelings and urges • Wants: anticipated pleasure or satisfaction • Needs: anticipated relief from mental or physical discomfort • Impulses: Habit and instinct • Counter-impulses: inhibitory processes

15. Opportunity • There have to be events and situations in the social and physical environment that enable or prompt the behaviour • Physical environment • enabling factors • cues/prompts • Social environment • modes of thinking/language • models

16. Motivation: reflective and automatic Beliefs about what is good and bad, conscious intentions, decisions and plans Reflective Automatic Emotional responses, desires and habits resulting from associative learning and physiological states

17. The rider and the elephant • The rider (our self-conscious reasoning processes) has to communicate with and influence the elephant to get anything done • The elephant (our emotional and impulsive processes) has its own desires which may conflict with those of the rider Haidt J (2006) The happiness Hypothesis

18. PRIME Theory: reflective and automatic processes www.primetheory.com

19. 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

20. Automatic Perception: acquiring information from the senses Associative learning:operant and classical conditioning Maturation: changes associated with growing older Habituation: decrease in response with exposure Sensitisation: increase in response with exposure Imitation: direct copying Identification: forming one’s own identity from perceptions of others Consistency disposition: generation of motives, ideas from similar ones Dissonance avoidance: negating or blocking uncomfortable beliefs Objectification: generating evaluations from likes and dislikes Chemical ‘insult’: pharmacological responses Physical ‘insult’: brain lesions Reflective Assimilation: acquiring information via communication Inference: induction and deduction Analysis: formal and informal calculation PRIME Theory: Change processes www.primetheory.com

21. The Behaviour Change Wheel: hub

22. Intervention functions (EPICTREME)

23. Behaviour Change Wheel: inner ring

24. Linking COM-B to intervention functions

25. Examples: Promoting smoking cessation

26. Policy options • Communication/ marketing Using print, electronic, telephonic or broadcast media • Guidelines Creating documents that recommend or mandate practice. This includes all changes to service provision • Fiscal Using the tax system to reduce or increase the financial cost • Regulation Establishing rules or principles of behaviour or practice • Legislation Making or changing laws • Environmental/ social planning Designing and/or controlling the physical or social environment • Service provision Delivering a service

27. Behaviour Change Wheel: complete

28. Education as part of tobacco control • Increasing knowledge and understanding about tobacco use and cessation • effect on life-expectancy • effect on pain and disability • effect on mental health • consequences of use of different forms of tobacco • importance of stopping as young as possible • effect on other people • tobacco industry tactics • best ways of stopping Targeting evaluations

29. Persuasion as part of tobacco control • Changing the way people feel about tobacco use • reminding of importance of stopping smoking • associating smoking with negative imagery • creating positive imagery around not smoking • making effective methods of stopping attractive • countering tobacco company promotion Targeting evaluations, emotion and impulse/inhibition

30. Incentivisation as part of tobacco control • Giving people rewards for not smoking • rewards for not taking up smoking • rewards for abstinence • rewards for use of effective methods of achieving abstinence Targeting evaluations, emotion, impulse/inhibition

31. Coercion as part of tobacco control • Punishing smoking • raising taxes • combating illicit supply • stigmatising smoking Targeting evaluations, emotion, impulse/inhibition

32. Training as part of tobacco control • Providing people with the skills to avoid or escape from tobacco use • refusal skills training • self-control training • training in effective use of cessation methods Targeting capability

33. Restriction as part of tobacco control • Making rules about what, when and where people can smoke • banning high-tar cigarettes • banning smoking in indoor public areas • banning smoking in cars with children in Targeting opportunity

34. Environmental restructuring as part of tobacco control • Restricting availability • removing vending machines • reducing outlet density • preventing sales to minors • Reducing smoking prompts • Reducing tobacco promotion • Reducing exposure to smoking in films etc Targeting opportunity

35. Modelling as part of tobacco control • Showing people attractive non-smoking models • refusing to smoke • stopping smoking • using effective cessation methods Targeting evaluations, emotion, impulse/inhibition

36. Enablement as part of tobacco control • Helping people resist or stop smoking • addressing psychological problems that pre-dispose to smoking • providing medicines to combat craving and withdrawal symptoms, block nicotine’s effects and substitute for positive functions • providing non-pharmacological substitutes for smoking • providing behavioural support to aid cessation Targeting capability

37. Other key considerations • Affordability • What can be afforded within the resources that can be devoted to it • Practicability • What is the best implementation that can be achieved • Acceptability • What is ethically and publicly acceptable

38. Understanding the context • Need the best, most specific information possible • Use this in the COM-B analysis to help decide the strategy

39. Relevant evidence from the UK • Education: • quitting younger, better use of NRT bought OTC, and more use of Stop Smoking Services • Persuasion: • more effective use of GP advice • Coercion: • more effective use of cost increases • Restriction: • examine how to make them work better • Enablement • Raise the quality and increase affordability of Stop-Smoking support Arnott D (Ed) All Party Parliamentary Group Report on Tobacco Control in England. London: ASH www.ash.org.uk

40. Education

41. Percentage of ever regular smokers who have quit for at least a year Green Line: A-C1; Blue Line: C2-E, Red Line: All Plateau in quitting at the crucial point in lifespan Smoking Toolkit Study: www.smokinginengland.info

42. Specialist Stop Smoking Services give the best results Significantly better than no aid adjusting for confounding variables, p<0.001 Data from www.smokinginengland.info; based on smokers who tried to stop in the past year who report still not smoking at the survey adjusting for other predictors of success (age, dependence, time since quit attempt, social grade, recent prior quit attempts, abrupt vs gradual cessation): N=7,939

43. But only used by a tiny minority of smokers Smoking Toolkit Study: www.smokinginengland.info

44. Little evidence for benefit of OTC NRT as currently used Data from www.smokinginengland.info; based on smokers who tried to stop in the past year who report still not smoking at the survey adjusting for other predictors of success (age, dependence, time since quit attempt, social grade, recent prior quit attempts, abrupt vs gradual cessation): N=7,939

45. Use of aids to cessation Smoking Toolkit Study: www.smokinginengland.info

46. Persuasion

47. Attempts to stop according to GP advice to stop smoking Smoking Toolkit Study: www.smokinginengland.info N=7611, p<0.001 for difference between offer of support/prescription and others

48. GP advice to stop smoking Percentage of smokers and recent ex-smokers for whom …; data from Smoking Toolkit Study, N=7611 www.smokinginangland.info

49. Use of aids to stop according to GP advice to stop smoking Offer of help is associated with greater use of prescription meds N=2714, p<0.001 for difference in use of aids Smoking Toolkit Study: www.smokinginengland.info

50. Association between smoking motives and attempts to quit in the past year Main barriers to quitting are identity and enjoyment Final model from forward stepwise logistic regression of attempt to stop in past 12 months on to beliefs about smoking. Odds ratios less than 1 represent negative associations. N=3033 Smoking Toolkit Study: www.smokinginengland.info