Behaviour change and tobacco use: from
theory to practice
Robert West
University College London
May 2012
1
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
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
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
4
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.
5
The COM-B Model
Does the person have the physical
or psychological ability to engage in
the behaviour?
6
Capability
• Physical
– anatomy and physiology
– physical skills, strength, speed and stamina (4Ss)
• Psychological
– knowledge and understanding
– mental skills, strength, speed and stamina (4Ss)
7
The COM-B Model
Does the person have the physical
or social opportunity to engage in
the behaviour?
8
Opportunity
• Physical opportunity
– physical and financial access
– prompts and cues
• Social opportunity
– language and concepts
– social rules and laws
9
The COM-B Model
Will the person’s plans, beliefs,
desires and impulses drive the
behaviour more than a competing
behaviour?
10
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)
11
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
12
PRIME Theory: the structure of human motivation
I will try not to
smoke
Smoking is
bad for me
Need a cigarette
Urge to smoke
www.primetheory.com
13
Motivation in the moment
Want that bar of
chocolate
Need to eat: hunger
Thoughts
(plans and
evaluations)
Desires
(wants and needs)
I intend to eat healthily
Need to stick to diet
Eating healthily is a
good idea
‘Urge’ to reach
for chocolate’
Impulses/
inhibition
Inhibition of urge
14
The ‘Law of Affect’
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
At every moment we act in pursuit of what we most
want or need at that moment
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
15
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)
16
Why plans do not get implemented?
17
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
18
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
19
Why plans do not get implemented?
Wants and needs arising
from the plan that are
too weak
Conflicting momentary
wants and needs
20
Why plans do not get implemented?
Conflicting learned and
unlearned impulses
Weak capacity for inhibition
Lack of energy for impulse
generation
21
Example
• Choose a target behaviour pattern
• What is driving that behaviour?
– Capability
• Physical
• Psychological
– Opportunity
• Physical
• Social
– Motivation
• Reflective
• Automatic
22
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
23
Common terms for methods for inducing behaviour
change
Capability
Motivation
Opportunity
24
Common terms for methods for inducing behaviour
change
Capability
Educate
Train
Help
Motivation
Opportunity
25
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
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
Offer
Provide
Prompt
Constrain
27
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.
28
Behaviour Change Wheel
Education
Persuasion
Incentivisation
Coercion
Taining
Restriction
Environmental restructuring
Modelling
Enablement
29
Behaviour Change Wheel
Education
Legislation
Persuasion
Communication/marketing
Incentivisation
Service provision
Coercion
Guidelines
Taining
Restriction
Environmental/social
planning
Environmental restructuring
Fiscal measures
Modelling
Regulation
Enablement
30
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’
31
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
32
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
33
% still not smoking
Addiction treatment is needed because
unaided success rates are usually very low
100
90
80
70
60
50
40
30
20
10
0
0
10
20
30
40
50
Weeks since quit date
Estimated relapse curve from unpublished data
34
Urges to smoke are strongest in the first few
weeks but can be present for at least a year
Unpublished data
35
Urges to smoke
Smoking
triggers
Reminders
Positive beliefs
about smoking
Want or need
to smoke
Urge to smoke
Nicotine
‘hunger’
36
Resolve note to smoke
‘Non smoking’
personal rule
Want or need
not to smoke
Resolve not
to smoke
Ability to inhibit
impulses
37
The battle over time between resolve and
urge to smoke
When the urge is stronger than resolve
and cigarettes are available, a lapse will occur
Urge to smoke
Time
Resolve
Strength of urge
38
The role of treatment is to keep these lines
as far apart as possible
Urge to smoke
Time
Resolve
Strength of urge
39
Aiding cessation
Promote cessation
Promote quit attempts
Aid quit attempts
Pharmacological treatment
Behavioural support
40
Behavioural support
Promote cessation
Promote quit attempts
Aid quit attempts
Drugs to reduce motivation to
smoke
Pharmacological treatment
Behavioural support
41
Pharmacological treatment
Promote cessation
Promote quit attempts
Aid quit attempts
Pharmacological treatment
Advice and support aimed at
boosting motivation, helping
with self-regulation, and
promoting effective use of
supporting activities
Behavioural support
42
Behavioural support
Behaviour Change Techniques ...
Address motivation
Enhance self-regulation
Promote adjunctive activities
Support the process
43
Behavioural support
Minimise motivation to smoke
Behaviour
Change Techniques ...
and maximise motivation not to
smoke
Address motivation
Enhance self-regulation
Promote adjunctive activities
Support the process
44
Behavioural support
Behaviour Change Techniques ...
Help to avoid and resist urges to
smoke
Address motivation
Enhance self-regulation
Promote adjunctive activities
Support the process
45
Behavioural support
Behaviour Change Techniques ...
Address motivation
Help smokers to make best use
of medication and other aids to
cessation
Enhance self-regulation
Promote adjunctive activities
Support the process
46
Behavioural support
Behaviour Change Techniques ...
Address motivation
Enhance self-regulation
Do necessary assessments,
build rapport, tailor treatment as
needed
Promote adjunctive activities
Support the process
47
Percentange increase in success
Effectiveness of medication options: 12
months’ sustained abstinence
20
18
16
14
12
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo
continuous abstinence rates; all medications used with some behavioural support
48
Percentange increase in success
Effectiveness of medication options: 12
months’ sustained abstinence
20
18
16
14
12
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
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
Percentange increase in success
Effectiveness of medication options: 12
months’ sustained abstinence
20
18
16
14
12
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
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
Percentange increase in success
Effectiveness of medication options: 12
months’ sustained abstinence
20
18
16
14
12
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
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
Percentange increase in success
Effectiveness of medication options: 12
months’ sustained abstinence
20
18
16
14
12
10
8
6
4
2
0
NRT
Bupropion
Varenicline
Nortriptyline
Cytisine
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
Percentange increase in success
Effectiveness of different forms of NRT
25
20
15
10
5
0
Gum
Patch
Nasal spray
Inhaler
Lozenge
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
Percentange increase in success
Different ways of using NRT
25
20
15
10
5
0
Patch + faster acting
form vs patch alone
Starting patch before
quit date vs on quit date
NRT for reduction vs
placebo
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
Behavioural support: effectiveness
10
9
8
7
6
Percent increase
5
in success
4
3
2
1
0
Face-to-face
individual
Face-to-face
group
Pro-active
telephone
Text
messaging
Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief
advice/written materials/no treatment
55
Behavioural support: effectiveness
10
9
8
7
6
Percent increase
5
in success
4
3
2
1
0
Face-to-face
individual
Face-to-face
group
Pro-active
telephone
Text
messaging
Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief
advice/written materials/no treatment
56
Behavioural support: effectiveness
10
9
8
7
6
Percent increase
5
in success
4
3
2
1
0
Face-to-face
individual
Face-to-face
group
Pro-active
telephone
Text
messaging
Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief
advice/written materials/no treatment
57
Behavioural support: effectiveness
10
9
8
7
6
Percent increase
5
in success
4
3
2
1
0
Face-to-face
individual
Face-to-face
group
Pro-active
telephone
Text
messaging
Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief
advice/written materials/no treatment
58
Behavioural support: effectiveness
10
9
8
7
6
Percent increase
5
in success
4
3
2
1
0
Face-to-face
individual
Face-to-face
group
Pro-active
telephone
Text
messaging
Data from Cochrane reviews; bars represent 95% CIs based on rate differences versus brief
advice/written materials/no treatment
59
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
60
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
61
BCTs for maximising self-regulatory
capacity
• Facilitate barrier identification
• Set graded tasks
and problem solving
• Advise on conserving mental
• Facilitate relapse prevention
resources
and coping
• Advise on avoidance of social
• Facilitate action
cues for smoking
planning/develop treatment
• Facilitate restructuring of social
plan
life
• Facilitate goal setting
• Advise on methods of weight
• Prompt review of goals
control
• Prompt self-recording
• Teach relaxation techniques
• Advise on changing routine
• Advise on environmental
Blue: present in 2+ BSPs tested by
restructuring
RCTs; Red: linked to higher success
rates in SSSs; Purple: Blue+Red
62
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
63
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
64
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
65
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
66
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?
67
What to measure: opportunity
• what situations will arise that are incompatible
with smoking?
• what situations will arise that prompt smoking?
68
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?
69
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
70