1. Addiction and behaviour change
Robert West
University College London
December 2012

2. Aims
To show how an overarching model of behaviour can help to understand addictive behaviours and develop effective intervention strategies for combating these
To draw lessons from this to development of more effective interventions for behaviour change more generally

3. Outline
A ‘synthetic model’ of behaviour (COM-B+PRIME) and a framework for describing behaviour change interventions (BCW)
An overview, using the BCW framework, of what has worked and what has not in combating addictive behaviours
What this tells us about developing interventions to combat addictive behaviours and lessons for behaviour change more generally

4. The COM-B model of behaviour
have the physical and psychological capability
have the physical and social opportunity
be more motivated to do it at the relevant time than anything else
For any behaviour to occur the individual or group must
Michie et al 2011 Implementation Sci

5. PRIME Theory and the structure of human motivation
West 2005 Theory of Addiction

6. PRIME Theory and Dual Process Theories
Affective
Reflective
Reflective
Impulsive
Action
Action
Impulsive

7. PRIME Theory: 1st law of motivation
At every moment we act in pursuit of our strongest motives (wants or needs) at that moment
Want: anticipated pleasure or satisfaction
Need: anticipated relief from, or avoidance of, mental or physical discomfort

8. PRIME Theory: 2nd law of motivation
Evaluations (beliefs about what is good and bad) and plans (self-conscious intentions to do or not do things) are important in controlling our actions if they create motives at the appropriate moments that are stronger than competing motives coming from other sources

9. PRIME Theory: 3rd law of motivation
Self-control (acting in accordance with plans despite opposing motivations) requires mental energy and depletes reserves of that energy

10. PRIME Theory: 4th law of motivation
Our identities (thoughts, images and feelings and feelings about ourselves) can be a powerful source of motives
Labels: the categories we think we belong to
Attributes: the features we ascribe to ourselves
Personal rules: imperatives about what we do and do not do

11. PRIME Theory: 5th law of motivation
Motives influence actions by creating impulses and inhibitions, which are also generated by habitual (learned) and instinctive (unlearned) associations; behaviour is controlled by the strongest momentary impulses and inhibitions

12. The rider and the donkey model of behaviour

13. Many other animals are possible!

14. 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.

15. Addiction as a context-sensitive disorder of motivation
Addiction involves repeated powerful motivation to engage in a purposeful behaviour that has no survival value, acquired as a result of engaging in that behaviour, with significant potential for unintended harm.
West R. Models of Addiction.
EMCDDA Insight Report

16. The rider and the horse model of addiction

17. Behaviours with significant addictive potential
nicotine
alcohol
opiates
stimulants
sedatives
cannabis
Use of
gambling
internet?

18. Combating addiction involves combating addictive behaviours (and their harms)
Promoting attempts at control/cessation
Prevention of relapse
Prevention of initiation
Prevention of escalation
Non-addictive use
Addictive use
Non-use
Promotion of harm reduction
Management of consequences

19. Intervention functions
Function label
Description
Education
Increasing knowledge or understanding
Persuasion
Using communication to induce positive or negative feelings or stimulate action
Incentivisation
Creating expectation of reward
Coercion
Creating expectation of punishment or cost
Training
Imparting skills
Restriction
Using rules to limit set boundaries around behaviours
Environmental restructuring
Changing the physical or social opportunities
Modelling
Providing an example for people to imitate or aspire to
Enablement
Increasing capability or opportunity other than by other intervention functions

20. Primary sources Alcohol and illicit drugs
Abraha et al (2012) Alcohol and Drug Misuse: A Cochrane Handbook: Oxford Wiley-Blackwell
Smoking
ASH (2010) Inquiry into the Effectiveness and Cost-Effectiveness of Tobacco Control: Submission to the All Party Parliamentary Group on Smoking and Health. London: Action on Smoking and Health

21. Aims to improve knowledge and understand about
Education
harms of the behaviour and benefits of stopping or not starting
best ways of avoiding uptake or stopping
Aims to improve knowledge and understand about
information is believed and provokes concern (about the behaviour) or hope (about change) or directs towards effective action
opportunities and capability are supportive
Can be effective when
information about harms of smoking
brief GP advice on smoking and alcohol consumption
Examples

22. Persuasion
provoke feelings of worry or concern about the addictive behaviour
undermine positive feelings about the behaviour and provoke positive feelings about change
Aims to
messages are attended to and engaged with
opportunities and capability are supportive
Can be effective when
some mass media campaigns on smoking
brief GP advice on smoking and alcohol consumption
Examples

23. Incentivisation
create anticipation of reward for avoiding, decreasing or reducing the addictive behaviour
Aims to
degree of incentive for those concerned is large enough with minimal undermining of other beneficial motivations
opportunities for ‘gaming’ are closed off
opportunities and capability are supportive
Can be effective when
financial incentives to promote cocaine abstinence
financial incentives for smoking cessation in pregnancy
Examples

24. Coercion
create anticipation of unpleasant consequences for engaging in the addictive behaviour
Aims to
the consequences are closely tied to the behaviour
the consequences are sufficiently unpleasant
opportunities and capability are supportive
Can be effective when
raising the financial cost of smoking, alcohol and illicit drugs
automatic penalties for alcohol-related offences
contingency contracting for illicit drug use
Examples

25. Training
develop cognitive, social and behavioural skills to resist motivation to engage in the addictive behaviour
Aims to
motivation to change is high
there is sufficient motivation etc. to do the training
opportunities and capability are supportive
Can be effective when
school-based social skills training can prevent illicit drug use in the short-term
cognitive bias retraining may reduce alcohol consumption
Examples

26. Restriction
set rules that prohibit or restrict the addictive behaviour
Aims to
they cannot easily be circumvented
they are well internalised
opportunities and capability are supportive
Can be effective when
cultural norms around alcohol consumption
gender-related cultural norms around smoking
Examples

27. Environmental restructuring
reduce opportunities to engage in the addictive behaviour
Aims to
cannot easily be circumvented
able to be implemented
Can be effective when
raising the legal age of sale
reducing density of alcohol outlets
restricting licensing hours
preventing tobacco marketing
Examples

28. Modelling
motivate avoidance, cessation or restriction of the addictive behaviour through identification and imitation
Aims to
there is strong identification with the model
opportunities and capability are supportive
Can be effective when
parental smoking cessation may reduce smoking in adolescence
Examples

29. Enablement
use diverse means to increase capability to resist motivation to engage in the addictive behaviour other than through education or training
Aims to
opportunity and motivation are supportive
Can be effective when
behavioural support can improve chances of success at stopping smoking
agonist and partial agonist therapy can improves chances of stopping smoking
opiate agonists and partial agonists can reduce heroin use
acamprosate can promote continued abstinence from alcohol
Examples

30. Key points: what kinds of intervention?
Behaviour change interventions that influence non-addictive behaviours can be expected to work to a significant degree with addictive behaviours
Combating addiction requires in addition:
special focus on the neurological and psychological disorders that pre-dispose to, and result from, the addictive behaviour
recognition of the importance of harm reduction and problem management

31. Key points: how to develop and implement improved interventions?
Recognise ‘addictive’ aspects of non-addictive behaviours
tame the horse, strengthen the rider and landscape the path
Always start with a comprehensive behavioural analysis of ‘what would it take’?
not what are the current barriers and facilitators
Use theory to go from this to a comprehensive intervention strategy