1 Using a better understanding of motivation to encourage and help smokers to stop Robert West University College London February 2007

But first a quiz For each statement just state whether it is ‘True’ or ‘False’ or leave it blank if you do not know

Smoking and Health 1.Stopping smoking at age 40 increases life expectancy by about 9 years 2.Stopping smoking at age 60 increases life expectancy by 1 year 3.Smoking has been found to increase risk of stroke

Smoking and health 4.Smokers are more likely to suffer from pre-eclampsia (dangerously high blood pressure during pregnancy) than non- smokers 5.Resting blood pressure typically goes down when people stop smoking 6.The weight gain that many smokers experience when they stop usually lasts less than a year

Clinical issues 7.The nicotine withdrawal symptom, irritability, usually last about 8 weeks 8.Brief opportunistic advice from a GP leads about 5% of smokers to stop for at least 6 months 9.Acute forms of nicotine delivery such as gum, lozenge and nasal spray have been found to reduce urges to smoke but nicotine patches have not

Clinical issues 10.The threshold for expired-air carbon monoxide concentration to detect smoking is usually set at 3+ ppm 11.Clinical trials have found that face-to-face counselling helps an average of 10% of smokers to stop for at least 6 months 12.Trials of nicotine patches for smoking cessation have been found to increase 12- month continuous abstinence rates by 5-7% compared with placebo

Pharmacology 13.The plasma half life of nicotine is typically less than 3 hours 14.Nicotine binds with greater affinity to the alpha4-beta2 NAch receptor than the alpha7 receptor 15.Smokers typically ingest between 1.0 and 1.5mg of nicotine per cigarette

Some questions about smoking and motivation 1.Should you ask a smoker if s/he wants to stop before offering help and support? 2.Should you advise a smoker who wants to stop to wait so they can plan ahead or allow them to stop now if they feel ready? 3.Should you encourage smokers to list the pros and cons of smoking to help motivate them to stop? 4.If a smoker has previously said they are not interested in stopping, should you raise the topic of smoking with them on another occasion? 5.What is the best advice you can give someone about what to do when they are tempted to smoke? 6.What is the best advice you can give to someone who has smoked a cigarette at a party after the quit date? 7.What is the single most important mental change when it comes to becoming an ex-smoker?

Outline 1.What do we mean by ‘motivation’? 2.What has to go into a model of motivation? 3.Constructing a more complete model of motivation: PRIME Theory 4.Applying PRIME theory to smoking

10 1. What is motivation

Motivation Motivation is: –what energises and directs our behaviour –given what we are capable of and have the opportunity to do, it determines what we do and don’t do – and when! Motivation OpportunityCapability Behaviour

12 2. What are the ingredients of a theory of motivation?

Why did he do that? He had planned to do it He thought it was the right thing to do He wanted to do it He needed to do it He did it without thinking

Plans Our lives are governed by plans –diaries –resolutions –intentions But we often... –abandon them –put them off –forget them –ignore them –suspend them

Choice and decision making 1.We... envision a goal are presented with an opportunity are presented with a problem 2.If we remember or are told ‘what to do’ we do it 3.Otherwise we try to work out what to do

Working out what to do If –we envision there being a ‘right answer’ we try to calculate it using one or more methods that we think apply Otherwise –we weigh up the pros and cons as best we can

Weighing up the pros and cons We investigate various courses of action and features that make them more or less attractive We revise our list of options and/or our evaluations of these options until we: –reach a satisfactory solution –believe we have worked out least bad of the unsatisfactory solutions –run out of time –get distracted –lose interest –give up

The role of feelings Feelings are experiences ranging from pleasure and pain, through hunger and thirst to happiness and sadness They influence our choices by: –making things attractive or unattractive –influencing the way we think about the options They influence our automatic reactions by: –acting as a stimulus –influencing the way that we react to other stimuli

Different types of feeling Physical feelings –e.g. pain, physical discomfort, sensory pleasure Drives –e.g. hunger, thirst Generalised emotions –e.g. anxiety, depression, happiness, curiosity, excitement, amusement, uplifted, awe-struck, disgust Targeted emotions –e.g. liking, disliking Motives –e.g. wants, needs, desires, urges

Willpower and self-control We experience conflict between what we ‘should’ do and what we feel impelled to so or want to do People show willpower or exercise self- control when they do what they believe they should do in the face of impulses, desires and needs to do something else

Our sense of self As we grow up and through adulthood we form images and beliefs about ourselves as we think we are and as we could be These generate feelings...

Incentives Economic –money! Moral/social –respect, approval, self-respect etc. Personal –pleasure, pain, comfort, satisfaction etc.

‘Automatic’ responses We encounter a situation or a stimulus and respond without thinking We experience an impulse to act in a particular way and just do it

Where do motivations come from? Instinct –we are hard-wired to react in particular ways Habit –repetition of a behaviour leads to it becoming ingrained Association –we come to experience feelings about things because they are associated with other things Memory –we remember past experiences Analysis –we apply our own version of logic and reasoning to ideas Communication –other people tell us what is good or bad etc. Imitation –we copy what we observe in others

25 3. Constructing a synthetic theory

The starting point for a synthetic model Humans are more or less instinctive, habit- driven, emotional decision-makers with a propensity to make and break plans, powerfully influenced by our social world, with a sense of identity which can act as a source of self-control

Responses Responses involve starting, stopping or changing an action sequence At each moment they are generated by the strongest of one or more competing impulses and inhibitory forces present at that moment Responses Impulses versus inhibitory forces

Impulses Impulses can be generated by –Triggers interacting with innate dispositions (instincts) and learned dispositions (habits) –‘Motives’: feelings of desire (anticipated pleasure or satisfaction) and/or need (anticipated relief from unpleasantness or tension) They decay quickly unless refreshed Responses Impulses versus inhibitory forces Triggers Motives

Motives can be generated by: –Reminders interacting with the level internal tension at the time –‘Evaluations’: beliefs about what is good/bad, right/wrong, useful/detrimental etc. Responses Impulses versus inhibitory forces Triggers MotivesReminders Evaluations

Evaluations are generated by: –Recall of observations –Analysis, inference –Accepting what others say –Motives –Plans Responses Impulses versus inhibitory forces Triggers MotivesReminders EvaluationsPlans

Plans are ‘mental actions’ generated when: –Actions are considered to be required in the future –Actions are considered to be more likely to meet desires or needs if undertaken at a future time –Actions meeting desires or needs do have a sufficient priority to be enacted at the moment Responses Impulses versus inhibitory forces Triggers MotivesReminders EvaluationsPlans

The human motivational system External environment (stimuli, information) Responses Impulses (urges etc.) Motives (wants etc.) Evaluations (beliefs) Plans (intentions) Internal environment (percepts, drives, emotional states, arousal, ideas, frame of mind) Flow of influence through the system External stimulation Internal stimulation

How the system runs The system has an ‘energy level’ (arousal) that drives and influences the interactions between its elements Motivation can be regarded as the shaping and direction of the propensity to act driven by the energy level

The importance of ‘the moment’ Everything we think, feel or do is a reaction to what happened just prior to that acting on our dispositions We only think about things when we are prompted to do so The way that we think or feel about things depends to some degree on the current circumstances Not thinking about things is an important ‘action’ subject to wants and needs (e.g. the need for relief from anxiety) Evaluations, wants, needs, impulses and plans only exist when triggered and otherwise have no influence

Dispositions Attributes of the motivational system at a given time that cause it to react in a particular way to particular events Dispositions Stimuli Reactions Psychological and physiological Responses, impulses/inhibitions, motives etc. Internal and externally generated Time

The origin and development of dispositions Dispositions Genetic endowment 1.Habituation/sensitisation - becoming less or more sensitive to repeated or ongoing stimuli 2.Associative learning - habit formation, classical conditioning 3.Explicit memory - images and thoughts recreated in response to cues Time Experience

The dispositional landscape Critical periods: small environmental forces send the individual down different paths Deep chreods: small forces will not lead to lasting change; the system will settle back once they are removed; but if the system is on a cusp a small force will tip it into a new path Environmental forces A model of disposition- environment interaction From Waddington ‘Tools for Thought’

Identity People differ in the propensity to think about themselves, the nature of the thoughts and feelings that they have, and how consistent and coherent these are Identity is a very important source of motives; it is the foundation of personal norms that shape and set boundaries on our behaviour Identity refers to a disposition to generate particular thoughts and feelings about ourselves

Self-control Self-control is a cornerstone of behaviour change. The moment-to-moment wants and needs arising from that must be strong enough to overcome impulses, wants and needs coming from other sources The exercise of self-control is effortful; it requires and uses up mental energy Self-control refers to wants and needs that stem from evaluations arising from our identity

40 4. Applying PRIME theory to smoking

The process of stopping smoking as identity change I will give up some time I am giving up smoking I have given up smoking completely I am trying to give up smoking I smoke and I am happy about my smoking... but I am not happy about my smoking I have given up smoking but not completely I have made plans to give up I do not smoke... I am not even thinking about giving up

While smoking When the smoker is led to think about his or her smoking, he or she may feel a desire or need to stop that varies in strength and urgency arising from one or more of the following: Worry about health Dislike of financial cost of smoking Guilt or shame at smoking Disgust with smoking Hope for success at stopping Hope for improvement in health with stopping Hope for improved self-esteem with stopping Commitment to a remembered intention to make a quit attempt 2. These conflict with and are mitigated by habit driven impulses and by a desire or need to smoke arising from one or more of the following: Anticipated enjoyment of a forthcoming cigarette Need for the forthcoming cigarette Concern about loss of self-esteem if the quit attempt fails Concern about unpleasant short-term effects of stopping Wanting or needing to hold on to the perceived benefits of smoking 3. Depending on the strength of the competing desires and needs, the conflict may result in: Putting the idea of stopping out of his or her mind Forming an intention to stop at some vaguely conceived future time point Forming a definite plan to stop at some future time point Deciding to stop immediately

Motivation to stop smoking Quit attempt Impulse to make a quit attempt Desire to stop smoking Need to stop smoking Positive evaluations of stopping smoking Anticipated self-respect Anticipated praise Fear of ill- health/death Disgust, annoyance with smoking Felt stigma Non-smoker ‘identity’ Beliefs about benefits of stopping smoking Cues/triggers Reminders Choice Only the flow of influence towards responses are shown Habit/instinct

Motivation not to stop smoking Not making attempt Inhibition of making a quit attempt Desire not to make attempt Need not to make attempt Negative evaluations of making attempt Anticipated enjoyment of smoking Anticipated benefits of smoking Anticipated loss of benefits Fears of failure Anticipated effort Smoker ‘identity’ Beliefs about likelihood of failure Cues/triggers Reminders Choice Only the flow of influence towards responses are shown Habit/instinct

While not smoking 1. On each occasion when the would-be ex- smoker is led to think about smoking, he or she experiences an urge to smoke arising from one or more of the following: A habit-driven impulse A need to smoke derived from ‘nicotine hunger’ A need to smoke derived from anticipated relief from negative mood A need to smoke derived from anticipated physical symptoms, e.g. mouth ulcers A desire to smoke derived from anticipated enjoyment or satisfaction A desire to smoke derived from anticipated benefits of smoking, e.g. weight loss 2. This competes with a desire or need for the smoker to stop himself or herself smoking which arises from one or more of: Commitment to the decision not to smoke Commitment to the identity of a non-smoker Worry about health Anticipated guilt or shame at having a cigarette Hope for improvement in health with stopping Anticipated disappointment at having wasted the effort expended thus far Anticipated effort required to acquire a cigarette 3. If the strength of the urge to smoke is greater than the inhibition arising from the desire or need not to smoke, and the opportunity to smoke is present, the would-be ex-smoker will: Smoke a cigarette but consider that the quit attempt is continuing Abandon the quit attempt but try to keep smoking within certain limits Abandon the quit attempt completely

Motivation to smoke Smoking Impulse to smoke Desire to smoke Need to smoke Positive evaluation of smoking Anticipated enjoyment Anticipated benefit Nicotine ‘hunger’ Unpleasant mood and physical symptoms Smoker ‘identity’ Beliefs about benefits of smoking Cues/triggers Reminders Habit/instinct Choice Only the flow of influence towards responses are shown

Inhibition of smoking Not smoking Inhibition Desire not to smoke Need not to smoke Negative evaluation of smoking Anticipated praise Anticipated self-respect Plan not to smoke Anticipated disgust, guilt or shame Fears about health Non-smoker ‘identity’ Beliefs about benefits of not smoking Cues/triggers Reminders Choice Only the flow of influence towards responses are shown Habit/instinct

Creating the decision to stop Generate motivational tension by: –frequent or persistent, high levels of want and need to make the change now accompanied by moderate to high levels of arousal –hope that the attempt to change will be successful Trigger impulses to make the change attempt by: –repeated calls to immediate action –modelling the behaviour

Opening lines When was the last time you tried to stop smoking? How long did it last? What did you use to help? What led you to back to smoking? It’s always worth having another go and there are lots of options to suit individual smokers which have been proved to help in research. Would you like to discuss these?

Supporting the decision to stop Reduce the frequency and intensity of impulses, needs and wants to revert –Identify the sources of impulses and motives –Develop a specific plan in each case to avoid, escape or minimise these Generate a strong commitment to a new identity with clear boundaries –Foster the ‘complete non smoker’ identity (smoking is not even an option, re-evaluation of place of smoking in their life) –Deal with lapses by re-asserting the new identity –‘One day at a time’ –Maximise both intrinsic and extrinsic motives for not smoking (e.g. avoiding shame, gaining self-respect)

Some questions 1.Should you ask a smoker if s/he wants to stop before offering help and support? 2.Should you advise a smoker who wants to stop to wait so they can plan ahead or allow them to stop now if they feel ready? 3.Should you encourage smokers to list the pros and cons of smoking to help motivate them to stop? 4.If a smoker has previously said they are not interested in stopping, should you raise the topic of smoking with them on another occasion? 5.What is the best advice you can give someone about what to do when they are tempted to smoke? 6.What is the best advice you can give to someone who has smoked a cigarette at a party after the quit date? 7.What is the single most important mental change when it comes to becoming an ex-smoker?