1 How can technology support behaviour change? The case of smoking cessation University College London October 2012 Robert West

Outline Understanding behaviour change Effective interventions for smoking cessation The application of technology The promise of technology Challenges ahead 2

COM-B: The three pillars of behaviour 3 Michie et al (2011) Implementation Science

The COM-B model of behaviour 4 Michie et al (2011) Implementation Science Physical and psychological capability: knowledge, skill, strength, stamina

The COM-B model of behaviour 5 Michie et al (2011) Implementation Science Reflective and automatic motivation: plans, evaluations, desires and impulses

The COM-B model of behaviour 6 Michie et al (2011) Implementation Science Physical and social opportunity: availability, prompts, reminders and cues

PRIME Theory and the structure of human motivation 7

The rider and the donkey model of behaviour 8

PRIME Theory and Dual Process Theories 9 Reflective Impulsive Action Reflective Impulsive Action Affective

10 PRIME Theory: 1 st law of motivation At every moment we act in pursuit of our strongest motives (wants or needs) at that moment –Want: anticipated pleasure or satisfaction –Need: anticipated relief from, or avoidance of, mental or physical discomfort

11 PRIME Theory: 2 nd law of motivation Evaluations (beliefs about what is good and bad) and plans (self-conscious intentions to do or not do things) can only control our actions if they create motives at the appropriate moments that are stronger than competing motives coming from other sources

12 PRIME Theory: 3 rd law of motivation Self-control (acting in accordance with plans despite opposing motives) requires mental energy and depletes reserves of that energy

13 PRIME Theory: 4 th law of motivation Our identities (thoughts, images and feelings and feelings about ourselves) can be a powerful source of motives –Labels: the categories we think we belong to –Attributes: the features we ascribe to ourselves –Personal rules: imperatives about what we do and do not do

14 PRIME Theory: 5 th law of motivation Motives influence actions by creating impulses and inhibitions, which are also generated by habitual (learned) and instinctive (unlearned) associations; behaviour is controlled by the strongest momentary impulses and inhibitions

15 The battle over time between resolve and urge/impulse Urge/impulse Time When the urge is stronger than resolve and the behaviour is available, a lapse will occur Resolve Strength of urge

16 Increase overall resolve Urge to smoke Time Resolve Strength of urge

17 Minimise dips in resolve Urge to smoke Time Resolve Strength of urge

18 Reduce overall urges Urge to smoke Time Resolve Strength of urge

19 Minimise exposure to triggers for urges Urge to smoke Time Resolve Strength of urge

20 Reduce experience of urges Urge to smoke Time Resolve Strength of urge

21 Promote blunting of urges Urge to smoke Time Resolve Strength of urge

22 Stage of change model versus the SNAP model Move people to the next stage with ‘stage-matched’ interventions’ Create motivational tension and triggers to ‘snap’ people into action and then support to prevent them snapping back People move through ‘stages’ on the way to achieving lasting change ‘Personal rules’ govern behaviour, and transitions between these rules occur as a result of ‘tension and triggers’

23 Sources of urges/impulses Urge/ impulse Positive beliefs Triggers Want or need Acquired drive’ Reminders

24 Sources of resolve Resolve to abstain Want or need to abstain Personal abstinence rule Ability to inhibit impulses Reminders Beliefs and feelings about the behaviour and abstinence

25 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. EducationIncreasing knowledge or understanding PersuasionUsing communication to induce positive or negative feelings or stimulate action IncentivisationCreating expectation of reward CoercionCreating expectation of punishment or cost TrainingImparting skills RestrictionUsing rules that limit engagement in the target behaviour or competing or supporting behaviour Environmental restructuring Changing the physical or social context ModellingProviding an example for people to aspire to or imitate EnablementIncreasing means/reducing barriers to increase capability or opportunity Comms/marketingUsing print, electronic, telephonic or broadcast media GuidelinesCreating documents that recommend or mandate practice. This includes all changes to service provision FiscalUsing the tax system to reduce or increase the financial cost RegulationEstablishing rules or principles of behaviour or practice LegislationMaking or changing laws Env/Soc PlanningDesigning and/or controlling the physical or social environment Service provisionDelivering a service

Policy options for tobacco control 26 Comms/marketingImprove impact and targeting of communications campaigns GuidelinesProvide clear evidence-based guidance to Local Authorities and promote effective adoption FiscalIncrease the financial cost of smoking through tax and enforcement RegulationRegulate to improve access to acceptable and effective nicotine substitutes LegislationLegislate to reduce exposure to tobacco industry marketing Env/Soc PlanningControl density and location of tobacco outlets Service provisionImprove healthcare systems to increase the impact of brief advice and cessation support

Department of Health Marketing Strategy

The 3Ts model (Tension-Triggers- Treatment) West (2005) BMJ Catastrophic pathways to smoking cessation

Potential reach 29

Digital media and communications campaigns ‘Stoptober’ Campaign 30

Stoptober principles Create an Autumn quitting event to generate quit attempts during a fallow season Use principles from PRIME Theory: –strong emphasis on ‘not a puff’ rule –eclectic motivational and self-regulatory support –adjunctive activities (e.g. medication, text messaging) –identification with other smokers who are quitting 31

Seasonal quitting patterns 32

SmokeFree28 (SF28) 33

Downloads of SF28 34

The Stoptober app ,000 downloads

Policy options for tobacco control 36 Comms/marketingImprove impact and targeting of communications campaigns GuidelinesProvide clear evidence-based guidance to Local Authorities and promote effective adoption FiscalIncrease the financial cost of smoking through tax and enforcement RegulationRegulate to improve access to acceptable and effective nicotine substitutes LegislationLegislate to reduce exposure to tobacco industry marketing Env/Soc PlanningControl density and location of tobacco outlets Service provisionImprove healthcare systems to increase the impact of brief advice and cessation support

Need for brief advice training Offer of support from a GP to all smokers appears to be the most effective form of brief advice Most smokers do not receive this 37

The NCSCT VBA online training module Focus on: –automatic motivation (emotional engagement) –physical opportunity (takes very little) –social opportunity (easy to initiate in consultation) –psychological capability (shows clear models of what to do) Make it easy: –20 minutes online –simple before and after assessment Reward –CPD credits through BMJ Learning 38

The VBA trailer 39

NHS stop-smoking practitioners Wide variability in outcomes between services and practitioners Low level of knowledge and skills in many practitioners 40

Online training and assessment 41

Lifeguide Open source Community of users ‘Powerpoint’ for internet intervention designers Built in functionality for assessing usage and experimentation 42

NCSCT training programme 43

Effect of NCTCS online training 44

NCSCT accreditation 45

Smoking cessation websites 46 Civljak 2010 Cochrane Reviews

Industry-sponsored sites 47 Based on Click2Quit Based on Happy Endings

StopAdvisor 48

Transparent development process 49

StopAdvisor pilot study 50 Recruited 204 smokers Mean pages viewed in 6.6 log-ins No social gradient 20% CO-verified abstinence >4weeks

MumsQuit 51

Text2Stop 52

Challenges The development cycle –Public health imperative –Commercialisation –Speed of innovation Evaluations –Choice of comparison conditions –Contamination 53

Conclusions: the promise Technology allows development of wide-reach behaviour change interventions at very low unit cost These can: –address any of the three pillars of behaviour: capability, motivation and opportunity –be accessible when needed –be dynamically tailored as necessary –be used as the sole intervention or as an adjunct –be fully automated or involve human input –be improved using a relatively rapid development cycle –provide a solid basis for theory testing 54

Conclusions: the present Limited evidence that digital interventions typically outperform written materials for motivationally focused behaviour change Most interventions are developed and promulgated without rigorous evaluation Where there is rigorous evaluation the results are highly variable There is pressure to take proven interventions and ‘adapt’ them without regard to potential for ‘effect slip’ 55

Conclusions: the future The traditional cycle of RCTs is too slow and unable to keep pace with technological development Need: –platforms for ‘Rapid Incremental Development’ (RID) –based on a solid foundation of behaviour change theory Close linkage between development and implementation (e.g. NCSCT) 56

A model for a technology of behaviour change 57 RCT Utopia or hell