1 Behaviour change and tobacco use: from theory to practice University College London May 2012 Robert West

2 Topics 9:35-30:30 Understanding behaviour –COM-B and PRIME 11:00-12:00 Helping people change –The BCW and BCTs 12:00-12:30 Tobacco addiction –what it is and how to help people get over it 13:30-16:00 Clinical experience –what is being done and how it can be improved 16:00-16:30 Conclusions –key ‘take-home’ messages and evaluation

3 Topics 9:35-30:30 Understanding behaviour –COM-B and PRIME 11:00-12:00 Helping people change –The BCW and BCTs 12:00-12:30 Tobacco addiction –what it is and how to help people get over it 13:30-16:00 Clinical experience –what is being done and how it can be improved 16:00-16:30 Conclusions –key ‘take-home’ messages and evaluation

4 Understanding behaviour For a behaviour to occur at a given time on a given occasion we must: 1.be able to do it 2.have the opportunity to do it 3.have stronger motivation to do it than not to, or to do something else

5 The COM-B Model Michie S, M van Stralen, West R (2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42.

6 The COM-B Model Does the person have the physical or psychological ability to engage in the behaviour?

7 Capability Physical –anatomy and physiology –physical skills, strength, speed and stamina (4Ss) Psychological –knowledge and understanding –mental skills, strength, speed and stamina (4Ss)

8 The COM-B Model Does the person have the physical or social opportunity to engage in the behaviour?

9 Opportunity Physical opportunity –physical and financial access –prompts and cues Social opportunity –language and concepts –social rules and laws

10 The COM-B Model Will the person’s plans, beliefs, desires and impulses drive the behaviour more than a competing behaviour?

11 Motivation Reflective –plans (self-conscious intentions) –evaluations (beliefs about what is good and bad) Automatic –desires (wants and needs) –instincts and habits (unlearned and learned impulses)

12 Focus on motivation All those brain processes that energise and direct our behaviour Includes: –automatic impulses e.g. to puff on a cigarette –desires e.g. wanting to stop smoking –evaluations e.g. thinking that smoking is bad –plans e.g. to stop smoking

13 PRIME Theory: the structure of human motivation I will try not to smoke Smoking is bad for me Need a cigarette Urge to smoke

14 Motivation in the moment Thoughts (plans and evaluations) Desires (wants and needs) Impulses/ inhibition I intend to eat healthily Eating healthily is a good idea Want that bar of chocolate Need to eat: hunger ‘Urge’ to reach for chocolate’ Need to stick to dietInhibition of urge

15 The ‘Law of Affect’ At every moment we act in pursuit of what we most want or need at that moment We want things that we imagine will give us pleasure or satisfaction We need things that we imagine will give us relief from mental or physical discomfort Beliefs about what is good or bad, and prior intentions have to work through momentary wants and needs Identity (images, feelings and thoughts, about ourselves) is an important source of wants and needs Identity (images, feelings and thoughts, about ourselves) is an important source of wants and needs

16 Identity Images Feelings Thoughts –Labels (e.g. I am an ex-smoker) –Attributes (e.g. I am healthy) –Rules (e.g. I do not smoke)

17 Why plans do not get implemented?

18 Why plans do not get implemented? Poorly formed plans lacking: a. clear boundaries b. specificity c. emotional force Poor recall of plans Inefficient processes for translating plans into motives Competing plans

19 Why plans do not get implemented? Evaluations that: a. are weak or incoherent b. fail to generate relevant imagery Inefficient processes for translating evaluations into motives Competing evaluations

20 Why plans do not get implemented? Wants and needs arising from the plan that are too weak Conflicting momentary wants and needs

21 Why plans do not get implemented? Conflicting learned and unlearned impulses Weak capacity for inhibition Lack of energy for impulse generation

22 Example Choose a target behaviour pattern What is driving that behaviour? –Capability Physical Psychological –Opportunity Physical Social –Motivation Reflective Automatic

23 Topics 9:35-30:30 Understanding behaviour –COM-B and PRIME 11:00-12:00 Helping people change –The BCW and BCTs 12:00-12:30 Tobacco addiction –what it is and how to help people get over it 13:30-16:00 Clinical experience –what is being done and how it can be improved 16:00-16:30 Conclusions –key ‘take-home’ messages and evaluation

24 Common terms for methods for inducing behaviour change CapabilityMotivationOpportunity

25 Common terms for methods for inducing behaviour change Capability Educate Train Help MotivationOpportunity

26 Common terms for methods for inducing behaviour change Capability Educate Train Help Motivation Expose to Inform Discuss Suggest Encourage Incentivise Ask Order Plead Coerce Force Opportunity

27 Common terms for methods for inducing behaviour change Capability Educate Train Help Motivation Expose to Inform Discuss Suggest Encourage Incentivise Ask Order Plead Coerce Force Opportunity Offer Provide Prompt Constrain

28 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.

29 Behaviour Change Wheel Education Persuasion Incentivisation Coercion Taining Restriction Environmental restructuring Modelling Enablement

30 Behaviour Change Wheel Education Persuasion Incentivisation Coercion Taining Restriction Environmental restructuring Modelling Enablement Legislation Communication/marketing Service provision Guidelines Environmental/social planning Fiscal measures Regulation

31 Behaviour Change Techniques Specific actions that aim to fulfil intervention functions: E.g. –Reward incompatible behaviour –Promote self monitoring –Promote anticipatory regret –Provide pharmacological support –Provide feedback on the target behaviour –Promote ‘self-talk’

32 Example Choose a target behaviour change What would need to be different for that behaviour to occur? –Capability Physical Psychological –Opportunity Physical Social –Motivation Reflective Automatic

33 Topics 9:35-30:30 Understanding behaviour –COM-B and PRIME 11:00-12:00 Helping people change –The BCW and BCTs 12:00-12:30 Tobacco addiction –what it is and how to help people get over it 13:30-16:00 Clinical experience –what is being done and how it can be improved 16:00-16:30 Conclusions –key ‘take-home’ messages and evaluation

34 Addiction treatment is needed because unaided success rates are usually very low Estimated relapse curve from unpublished data

35 Urges to smoke are strongest in the first few weeks but can be present for at least a year Unpublished data

36 Urges to smoke Urge to smoke Want or need to smoke Positive beliefs about smoking Smoking triggers Want or need to smoke Nicotine ‘hunger’ Reminders

37 Resolve note to smoke Resolve not to smoke Want or need not to smoke ‘Non smoking’ personal rule Ability to inhibit impulses

38 The battle over time between resolve and urge to smoke Urge to smoke Time When the urge is stronger than resolve and cigarettes are available, a lapse will occur Resolve Strength of urge

39 The role of treatment is to keep these lines as far apart as possible Urge to smoke Time Resolve Strength of urge

40 Aiding cessation Promote cessation Promote quit attempts Aid quit attempts Pharmacological treatment Behavioural support

41 Behavioural support Promote cessation Promote quit attempts Aid quit attempts Pharmacological treatment Behavioural support Drugs to reduce motivation to smoke

42 Pharmacological treatment Promote cessation Promote quit attempts Aid quit attempts Pharmacological treatment Behavioural support Advice and support aimed at boosting motivation, helping with self-regulation, and promoting effective use of supporting activities

43 Behavioural support Behaviour Change Techniques... Address motivation Enhance self- regulation Promote adjunctive activities Support the process

44 Behavioural support Behaviour Change Techniques... Address motivation Enhance self- regulation Promote adjunctive activities Support the process Minimise motivation to smoke and maximise motivation not to smoke

45 Behavioural support Behaviour Change Techniques... Address motivation Enhance self- regulation Promote adjunctive activities Support the process Help to avoid and resist urges to smoke

46 Behavioural support Behaviour Change Techniques... Address motivation Enhance self- regulation Promote adjunctive activities Support the process Help smokers to make best use of medication and other aids to cessation

47 Behavioural support Do necessary assessments, build rapport, tailor treatment as needed

48 Effectiveness of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

49 Effectiveness of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

50 Effectiveness of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

51 Effectiveness of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

52 Effectiveness of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

53 Effectiveness of different forms of NRT Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

54 Different ways of using NRT Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

55 Behavioural support: effectiveness Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

56 Behavioural support: effectiveness Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

57 Behavioural support: effectiveness Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

58 Behavioural support: effectiveness Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

59 Behavioural support: effectiveness Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief advice/written materials/no treatment

60 Topics 9:35-30:30 Understanding behaviour –COM-B and PRIME 11:00-12:00 Helping people change –The BCW and BCTs 12:00-12:30 Tobacco addiction –what it is and how to help people get over it 13:30-16:00 Clinical experience –what is being done and how it can be improved 16:00-16:30 Conclusions –key ‘take-home’ messages and evaluation

61 BCTs for addressing motivation Provide information on consequences of smoking and smoking cessation Boost motivation and self efficacy Provide feedback on current behaviour and progress Provide rewards contingent on successfully stopping smoking Provide normative information about others' behaviour and experiences Prompt commitment from the client there and then Provide rewards contingent on effort or progress Strengthen ex-smoker identity Conduct motivational interviewing Identify reasons for wanting and not wanting to stop smoking Explain the importance of abrupt cessation Measure carbon monoxide (CO) Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs; Purple: Blue+Red

62 BCTs for maximising self-regulatory capacity Facilitate barrier identification and problem solving Facilitate relapse prevention and coping Facilitate action planning/develop treatment plan Facilitate goal setting Prompt review of goals Prompt self-recording Advise on changing routine Advise on environmental restructuring Set graded tasks Advise on conserving mental resources Advise on avoidance of social cues for smoking Facilitate restructuring of social life Advise on methods of weight control Teach relaxation techniques Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs; Purple: Blue+Red Facilitate barrier identification and problem solving Facilitate relapse prevention and coping Facilitate action planning/develop treatment plan Facilitate goal setting Prompt review of goals Prompt self-recording Advise on changing routine Advise on environmental restructuring Set graded tasks Advise on conserving mental resources Advise on avoidance of social cues for smoking Facilitate restructuring of social life Advise on methods of weight control Teach relaxation techniques

63 BCTs for promoting use of adjunctive activities Advise on stop-smoking medication Advise on/facilitate use of social support Adopt appropriate local procedures to enable clients to obtain free medication Ask about experiences of stop smoking medication that the smoker is using Give options for additional and later support Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs; Purple: Blue+Red

64 BCTs for supportive activities: general and assessment Tailor interactions appropriately Emphasise choice Assess current and past smoking behaviour Assess current readiness and ability to quit Assess past history of quit attempts Assess withdrawal symptoms Assess nicotine dependence Assess number of contacts who smoke Assess attitudes to smoking Assess level of social support Explain how tobacco dependence develops Assess physiological and mental functioning Blue: present in 2+ BSPs tested by RCTs

65 Smoking cessation: Supportive activities: communication Build general rapport Elicit and answer questions Explain the purpose of CO monitoring Explain expectations regarding treatment programme Offer/direct towards appropriate written materials Provide information on withdrawal symptoms Use reflective listening Elicit client views Summarise information / confirm client decisions Provide reassurance Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs

66 The behaviour change task... What will it take to achieve the change? Capability: –knowledge, capacity for self-regulation Opportunity: –positive prompts and cues, absence of negative prompts and cues, access Motivation: –commitment to clear rules governing change supported by beliefs, feelings and habits that maintain the motivation to change above motivation to lapse at all times

67 What to measure: capability do they know what they have to do? do they have the skills needed? how strong will the cravings be? how bad will the mood and physical symptoms be? do they have the mental energy? do they have the capacity for self-control?

68 What to measure: opportunity what situations will arise that are incompatible with smoking? what situations will arise that prompt smoking?

69 What to measure: motivation how well formulated is their no smoking rule? how much commitment can they give to that rule? how variable will that commitment be? how much do they really want to stop? how much do they want to carry on? how strong are the associations between smoking and particular situations? how strong are the positive beliefs about smoking?

70 Topics 9:35-30:30 Understanding behaviour –COM-B and PRIME 11:00-12:00 Helping people change –The BCW and BCTs 12:00-12:30 Tobacco addiction –what it is and how to help people get over it 13:30-16:00 Clinical experience –what is being done and how it can be improved 16:00-16:30 Conclusions –key ‘take-home’ messages and evaluation