Psychological principles underpinning behavioural support Robert West University College London January 2009

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

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

Does behavioural support work? Systematic reviews show clear benefit from: 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

Five key principles From PRIME Theory: Maximise continued desire to maintain engagement with behavioural support Minimise strength and frequency of desire to smoke Maximise strength of desire not to smoke when needed Maximise capacity for self-control when needed Maximise effective use of supporting behaviours (e.g. medication usage)

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

Minimise desire to smoke Desire stems from: smoking cues ‘nicotine hunger’ unpleasant withdrawal symptoms beliefs about benefits of smoking Approaches to reducing desire avoiding and escaping cues distraction exercise medication re-appraisal of negative symptoms re-appraisal of beliefs about smoking promoting ‘deep’ identity change

Maximising desire not to smoke Desire stems from 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 fostering bond with client fostering appropriate new identity generating negative images of smoking focusing attention on positive feelings associated with not smoking

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 (self-labels 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

Maximising use of supporting behaviours Use of supporting behaviours (e.g. medication use, exercise) derives from 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

Behavioural support strategies in use Brainstorming session by 80 tobacco control practitioners from >10 countries at workshop in 2007 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 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

Techniques from authoritative sources 1 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 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

Techniques from authoritative sources 2 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 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

Review Behavioural support addresses needs that medication does not improves usage of medication is effective needs to focus on 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