Psychological principles underpinning
behavioural support
Robert West
University College London
January 2009
1
Sources
• Cochrane reviews
• West R (2006) Theory of Addiction. Oxford:
Blackwells (see also www.primetheory.com)
• Shahab et al (2009) Report to Department of
Health
• www.treatobacco.net
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Why behavioural support is often needed
• After the start of the ‘quit attempt’ smokers:
– can experience powerful, frequent and/or persistent feelings of desire
(want or need) to smoke (PRIME Theory)
– reductions in desire to remain abstinent
– reduced capacity to exercise self-control
• Medication can
– reduce the desire to smoke
• But
– there are limits to how much
– smokers often need behavioural support to optimise usage and benefits
– behavioural support may be needed to address sources of desire to
smoke that medication does not
– behavioural support may be needed to maximise desire not to smoke
and capacity for self control
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Does behavioural support work?
• Systematic reviews show clear benefit from:
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Individual face-to-face
group face-to-face
telephone-based
internet-based
• delivered to
– smokers in general
– hospital inpatients
– pregnant smokers
• On average approx 1 in 20 smokers are helped at each quit attempt
• Benefit appears to accumulate with successive quit attempts
• But there is little evidence on what elements and combinations of
elements of behavioural support are important
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Five key principles
From PRIME Theory:
1. Maximise continued desire to maintain
engagement with behavioural support
2. Minimise strength and frequency of desire to
smoke
3. Maximise strength of desire not to smoke when
needed
4. Maximise capacity for self-control when needed
5. Maximise effective use of supporting
behaviours (e.g. medication usage)
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Ideas for motivating engagement
• Create an image of the next appointment that meets
wants and needs
– Be appropriately friendly and warm
– Establish credibility as someone who can help
– Make specific arrangements for next contact and set up feeling
of positive expectation
– Use reminders where appropriate
– Create sense of ‘identity’ for the person or ‘team’ providing
support (e.g. showing knowledge from previous session)
– Set up non-threatening opportunity for the client to report on
experiences
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Minimise desire to smoke
• Desire stems from:
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smoking cues
‘nicotine hunger’
unpleasant withdrawal symptoms
beliefs about benefits of smoking
• Approaches to reducing desire
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avoiding and escaping cues
distraction
exercise
medication
re-appraisal of negative symptoms
re-appraisal of beliefs about smoking
promoting ‘deep’ identity change
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Maximising desire not to smoke
• Desire stems from
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commitment to new identity as non-smoker
concerns about harms of smoking
positive feelings about not smoking
extrinsic motives (e.g. pleasing the counsellor)
• Approaches to maximising desire
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fostering bond with client
fostering appropriate new identity
generating negative images of smoking
focusing attention on positive feelings associated with
not smoking
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Maximising capacity for self-control
• Self-control stems from
– strong commitment to specific rules with clear boundaries
– sufficient mental energy
– establishing conditions that minimise temptation
• Approaches to maximising self-control
– establishing specific rules that create as strong a sense of
‘external agency’ as possible
– support the rules with changes to other aspects of identity (selflabels and attributes)
– establish rules to minimise competing demands on mental
energy (e.g. stress, other self-control needs)
– establish rules for minimising exposure to smoking cues or
situations that generate the want or need to smoke
– develop skills for monitoring and responding to cues and desires
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Maximising use of supporting behaviours
• Use of supporting behaviours (e.g. medication use,
exercise) derives from
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high feeling of need for the behaviour
low concerns over negative effects of the behaviour
good understanding of how and when
presence of prompts
• Approaches to maximising supporting behaviours
– provide a menu of potential activities with clear explanation of
what is involved, what needs are addressed and how, and
address any potential concerns
– establish clear rules for when, what and how and explain why
– check understanding of the above
– reappraisal of beliefs about supporting behaviours
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Behavioural support strategies in use
Brainstorming session by 80 tobacco control practitioners
from >10 countries at workshop in 2007
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Assessment
Setting quit date
Providing reassurance
Addressing smoker’s concerns
Developing rapport
Giving CO feedback
Discussing medication
Focus on money saved
Focus on health gains
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Agreeing a follow up
Developing social support
Discussing environmental change
Developing a personalised plan
Developing alternative behaviours
Giving praise
Structuring the day
Preparing for potential difficulties
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Techniques from authoritative sources 1
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Establish smoking history
Assess past history of quit
attempts
Assess current readiness and
ability to quit
Identify client’s reasons for
wanting and not wanting to stop
smoking/ keep stopped
Provide information on positive or
negative consequences of
behaviour
Explain expectations
Provide advice/ information about
medication
Enquire about medication
Offer incentive of free medication
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Provide information on withdrawal
symptoms
Enquire about withdrawal
symptoms
Provide normative information
about others’ behaviour and
experiences
Explain the importance of abrupt
cessation
Goal setting
Action planning
Environmental restructuring
Social restructuring
Barrier identification and Problem
solving
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Techniques from authoritative sources 2
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Relapse prevention and Coping
planning
Provide feedback on performance
Prompt review of set goals
Provide Reassurance (unspecified
how)
Boost Motivation/ Self Efficacy
Elicit and answer questions
Elicit client views
Emphasise client choice
Give client option of additional or
later support
Summarise information / confirm
client decisions
Set graded tasks
Provide rewards contingent on
successfully stopping smoking
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Provide rewards contingent on
effort or progress towards
stopping smoking
Explain the purpose of CO
monitoring
Measure CO
Build general rapport
Use reflective listening
Offer written information
Prompt self recording
Provide advice on conserving
resources
Tailor interaction to be appropriate
to individual clients
Prompt commitment from the
client there and then
Strengthen ex-smoker identity
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Review
• Behavioural support
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addresses needs that medication does not
improves usage of medication
is effective
needs to focus on
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maximising continued engagement
minimising desire to smoke
maximising motivation not to smoke
maximising capacity for self-control
optimising use of supporting activities (e.g. medication)
– everything hinges on control of moment-to-moment
desire (wants and needs) to prevent desire to smoke
exceeding desire not to
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