Addiction and behaviour change Robert West University College London December 2012

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

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

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

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

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

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

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

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

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

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

The rider and the donkey model of behaviour

Many other animals are possible!

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.

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

The rider and the horse model of addiction

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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