1 Theory and practice of helping people change their behaviour: the case of smoking cessation University College London 2010 Robert West

2 Outline Behaviour as part of a system Motivation and behaviour change Helping smokers to stop

3 Outline Behaviour as part of a system Motivation and behaviour change Helping smokers to stop

4 The ‘behaviour system’ Opportunity Capability Motivation Behaviour

5 The ‘behaviour system’ Opportunity Capability Motivation Behaviour Physical and mental ability: changeable by education, training, enablement/resources Values, desires and habits: changeable by education, persuasion, inducement, punishment, stimulus control Physical and psychological/social availability: changeable by restrictions, education, persuasion, enablement/resources

6 Policy options Mass media communication Environmental restructuring Fiscal measures Legislation Service provision Regulation Guidelines

7 The Behaviour Change Wheel Regulation Environmental restructuring Mass media Legislation Fiscal Persuasion Education Coercion Stimulus control Inducement (incentives/rewards) Enablement/ resources Capability Opportunity Physical Psych/ social Emot/ Habit Rational d-m Psych Motivation Behavioural targets Intervention Options Policy Options Training Michie & West, 2010 Restriction Service provision Guidelines

8 Outline Behaviour as part of a system Motivation and behaviour change Helping smokers to stop

9 The structure of human motivation

10 The structure of human motivation Starting, stopping or modifying actions Generated by the strongest of competing impulses and inhibitions at that moment Lighting up a cigarette Taking a puff on a cigarette Saying no to offer of a cigarette

11 The structure of human motivation Impulses and inhibitions: patterns of activation in CNS pathways that organise and impel or block specific actions Formed from strongest of competing learned and unlearned stimulus-impulse associations Motives are important triggering stimuli Impulses are experienced as urges when blocked Vary in strength Impulse to light up a cigarette Inhibition of impulse to light up

12 The structure of human motivation Feelings of desire or attraction or repulsion in relation to something that is imagined Want: anticipated pleasure or satisfaction Need: anticipated relief from mental or physical discomfort Formed when stimulus generates image to which past experience has associated positive or negative feelings Can vary in strength Want to smoke Need a cigarette Want to stop smoking

13 The structure of human motivation Beliefs (internalised statements) that something is good or bad Formed from acceptance of communication or when stimulus triggers recall of plans, memory of beliefs, plans, wants and needs, or inference Must generate motive (want or need) to influence behaviour Can vary in strength of adherence, ambivalence, extremity, valence Smoking is harming my health and costing me a lot of money I ought to stop smoking

14 The structure of human motivation Self-conscious intentions to behave in a particular way (personal rule) or perform an action (one-off plan) in the future Formed when positive evaluation of action outweighs negative one Must be remembered and generate positive evaluation to be enacted Can vary in: commitment, starting conditions, specificity One off: I will stop smoking tomorrow Personal rule: I will not smoke

15 Controlling purposeful behaviour We act in pursuit of what we most desire (want or need) at every moment Beliefs about what is good or bad and prior intentions can only influence behaviour if they generate sufficiently strong desire at the key moments Behaviour is under the continuous control of stimuli that generate desires which have been shaped by prior associations with positive and negative feelings Control over behaviour involves making and breaking associations and controlling the triggering stimuli This includes triggering plans and shaping plans so that they generate strong desires

16 Identity, rules and self-control We can form mental representations of ourselves (identities) which are an important source of desires A major part of our identity involves ‘personal rules’ (types of plan) Self-control involves domination of desires arising from personal rules Failure of self control arises when desires arising from personal rules (‘oughts’) are insufficient

17 Routes to behaviour change Deliberate –change in personal rules Non-deliberate –change in opportunity capability emotional responses or habits

18 The process of deliberate behaviour change Starts with is a rule in which person defines him/herself as –attempting (‘I am trying to change’) –engaging in the new behaviour (‘I have changed’) People plan a change attempt when –the feeling of ‘want’ or ‘need’ to change at a future date exceeds the desire to continue People make a change attempt when –the want or need to change now exceeds the want or need to carry on People lapse when –the want or need to revert at a given moment exceeds the want or need to stick to the rule –the rule is still in force People relapse when –the want or need to abandon the change attempt exceeds the want or need to continue with it Stay with old beh Planning Attempting New behaviour Pre-quit Post-quit SNAP: 4 states based on the rules smokers apply to themselves

19 SNAP versus ‘Stages of Change’ SNAPStages of Change Focus on momentary desire to change Focus on stable intention to change Readiness to change is a state Readiness to change is a stage Transition can occur between any state and any other Transitions must be progressive Importance of identity and the nature of the personal rule Importance of beliefs about pros and cons of change

20 Outline Behaviour as part of a system Motivation and behaviour change Helping smokers to stop

21 Features of smoking cessation Smokers who seek help already want to stop and are mostly willing to set a quit date after which they will stop completely The major barriers for them are probably: –powerful urges arising from the way nicotine acts on the motivational system –unpleasant mood and physical withdrawal symptoms –lack of alternative sources of reward –many opportunities for lapse –lack of immediate negative consequences of lapse

22 Helping smokers to stop Combination of –behavioural support –medication Together there is strong evidence that this increases chances of success by 300% It is available throughout the UK, free on the NHS

23 Behavioural support Advice, proposed activities, discussion and encouragement aimed at helping people to achieve lasting change in behaviour patterns Includes a number of ‘behaviour change techniques’ (BCTs) aimed at 1.reducing the motivation to engage in undesired behaviour and increasing the motivation to engage in desired behaviour 2.increasing the capacity for self-regulation 3.increasing effective adoption of adjunctive activities 4.supporting the above

24 Classification of BCTs by function BCTs Focus on specific behaviour Address motivation Maximise self- regulation Promote adjuvant activities Supportive actions

25 Data from English Stop Smoking Services: West et al (In press) 37 services provided treatment manuals and data coded for number of times mentioned each of a number of behaviour change techniques (BCTs): using taxonomy developed by Susan Michie likelihood of a smoker achieving 4-week CO-verified abstinence as recorded by the service was predicted by exposure to each of the BCTs using logistic regression N=177,064 smokers Looked at significant associations between number of time BCT cited in manual and 4-week success rate by both self-report only and CO-verified self-report

26 BCTs associated with higher success rates: motivation Measure CO Strengthen ex-smoker identity Provide ‘rewards’ (usually praise or tokens of success) contingent on successfully stopping smoking

27 BCTs associated with higher success rates: self-regulation Advise on changing routine Facilitate relapse prevention and coping planning

28 BCTs associated with higher success rates: adjuvant activities Advise on stop smoking medication Ask about experiences of stop smoking medication that the smoker is taking Give options of additional or later support

29 BCTs associated with higher success rates: supportive actions Elicit client views

30 Summary Behaviour can be usefully viewed as part of a system in which there are possibilities for change in: capability, motivation and opportunity Intervention and policy options can be mapped on to this system Motivation is particularly important in many areas and it is important to recognise that the target is typically control of momentary desires Deliberate behaviour change involves establishing personal rules that generate momentary desires that have sufficient force to overcome strong competing desires Analysis of the data from the English Stop Smoking Services suggests particular behaviour change techniques that, in that context, are associated with greater effectiveness