Robert West University College London How do people change? Robert West University College London This slide set provides top line results from the Smoking Toolkit Study (STS), a series of national surveys looking at smoking and smoking cessation patterns on a monthly basis. The aims of the STS are: To provide up-to-date key performance indicators on smoking and smoking cessation to help determine effects of societal interventions (such as price rises, smoke-free legislation) and other events (such as New Year, No Smoking Day, introduction of new treatments) To assess associations between smoking and smoking cessation indicators and sociodemographic factors (age. sex, social grade, region) To provide a toolkit that can be used to answer important questions about the process of stopping smoking, incidence and effectiveness of different methods of stopping, associations between harm reduction activities and cessation, attitudes to policy initiatives, cost of smoking and others.

Outline What is behaviour change? What can change? Pathways to change Mechanisms of change Dynamics of change Transtheoretical model A better model Example of smoking

What is ‘behaviour change’? Behaviour patterns are characteristic ways of responding to situations and events Behaviour change is a change in those ways of responding It can occur as a result of change to: the situations and events to which the individual is exposed the way that the individual responds

What can change? ‘External’ change in the environment cues and reminders opportunity models ‘Internal’ change in the individual plans beliefs desires habits emotions capabilities

The structure of human motivation Response generation systems Primitive, inflexible Level 1: Instinctive and habit learning mechanisms Impulse/inhibition generation systems Level 2: Feelings attached to mental representations of possible futures Motive generation systems Level 3: Increasing flexibility and complexity Evaluation generation systems Level 4: Generates beliefs Plan generation and enactment systems Allows greatest flexibility and anticipation Level 5:

Pathways to internal change Deliberate a decision is made to make a change this leads to changes to motivation Unconsidered change occurs without a conscious decision to do so

Deliberate change Self-conscious intention to behave differently Creates new desires that: compete with existing desires and habits can changes existing desires can involve other behaviours that facilitate the change

Non-deliberate change Habituation-sensitisation emotional responses to events decrease or increase with continued or repeated exposure Associative learning emotional responses to events or situations are altered by their association with other events or situations Cognitive adjustment levels of attraction are changed through inference, communication etc.

The Transtheoretical Model 5 stages of change precontemplation contemplation preparation action maintenance Processes of change different processes for each stage transition

Problems with the model Descriptively inaccurate ‘stages’ do not exist in any meaningful sense change process is fluid and variable Predictively weak ‘stage’ is a weaker predictor than desire intention Barriers (e.g. dependence) Heuristically unhelpful interventions based on the TTM have not proved more effective than those based on other models or simple commonsense approaches emphasis of ‘stage’ may lead to inappropriate intervention approach

A more accurate model Deliberate change involves two phases: initiation attempted maintenance Initiation arises from two drivers: momentary tension immediate degree of dissatisfaction with current situation and hope for an improved situation triggers events that precipitate the decision to change Initiation takes two forms: immediate change intention to change

Attempted maintenance Involves two channels behaviour the behaviour may conform more or less closely to the new identity identity the new identity may involve different degrees of: coherence commitment specificity

Behaviour maintenance Momentary balance of competing motivations given cues and opportunity old instincts, old habits, old desires, old beliefs versus new identity-driven desire, new beliefs, new habits etc. Higher-level motivations require more mental mental energy

The importance of identity change Identity change is the basis for the desire to inhibit the old behaviour or engage in the new behaviour Commitment to a coherent, specific new identity is essential to maintain behaviour change unless other changes take places to desires, habits etc. that will sustain the new behaviour

Lasting behaviour change Lasting behaviour change requires minimal self-regulatory effort reduction in old habits, old desires etc. development of new habits, new desires etc. changes to environment that minimise exposure to cues and opportunities that rekindle old habits, old desires etc. or maintain new ones

Initiation of smoking cessation Drivers of initiation Tension concern about health, cost etc. Triggers momentary increases in concern caused by illness, price rise, inconvenience Form of initiation 50% of decision are put into effect immediately

Maintenance of smoking cessation Attempts at maintenance Behaviour lapses caused by anticipated pleasure or relief of craving or discomfort in presence of cues or reminders overwhelming desire arising from new identity Identity observation that lapses are inconsistent with non-smoker identity results in reversion to smoker identity

Lasting maintenance No longer finds smoking attractive Extinction of cues driven urges Competing behaviours have greater priority Environment is no longer conducive to old behaviour or is conducive to new one Fixed barrier around the behaviour

Conclusions Model of behaviours change needs to: diversity of pathways responsiveness to immediate situation the importance of identity change importance of desire and habit