1. 1 The Psychology of Smoking Cessation Robert West University College London Oslo November 2006

2. 2 Outline Understanding human motivation Addiction to cigarettes The process of smoking cessation Interventions to promote smoking cessation

3. 3 Human motivation Humans are more or less instinctive, habit- driven, emotional decision-makers with a propensity to plan ahead, powerfully influenced by our social world, with a sense of identity which can act as a source of self-control

4. 4 Responses At every moment our behaviour is generated by the balance between impulses and inhibitory forces active at that precise moment Responses Impulses versus inhibitory forces

5. 5 Impulses Impulses can be generated by –Triggers interacting with innate dispositions (instincts) and learned dispositions (habits) –‘Motives’: feelings of desire (anticipated pleasure or satisfaction) and/or need (anticipated relief from unpleasantness or tension) They decay quickly unless refreshed or sustained by triggers or motives Responses Impulses versus inhibitory forces Triggers Motives

6. 6 Motives can be generated by: –Reminders interacting with the level internal tension at the time –‘Evaluations’: beliefs about what is good/bad, right/wrong, useful/detrimental etc. Responses Impulses versus inhibitory forces Triggers MotivesReminders Evaluations

7. 7 Evaluations are generated by: –Recall of observations –Analysis, inference –Accepting what others say –Motives –Plans Responses Impulses versus inhibitory forces Triggers MotivesReminders EvaluationsPlans

8. 8 Plans are ‘mental actions’ generated when: –Actions are considered to be required in the future –Actions are considered to be more likely to meet desires or needs if undertaken at a future time –Actions meeting desires or needs do have a sufficient priority to be enacted at the moment Responses Impulses versus inhibitory forces Triggers MotivesReminders EvaluationsPlans

9. 9 The human motivational system External environment (stimuli, information) Responses Impulses (urges etc.) Motives (wants etc.) Evaluations (beliefs) Plans (intentions) Internal environment (percepts, drives, emotional states, arousal, ideas, frame of mind) Flow of influence through the system External stimulation Internal stimulation

10. 10 The importance of the moment Everything we think, feel or do is a reaction to what happened or our state just prior to that acting on our dispositions We only think about things when we are prompted to do so The way that we think or feel about things depends to some degree on what prompted this Not thinking about things is an important method of reducing tension Evaluations, wants, emotional states, impulses and plans are only present when triggered and have no influence when not present

11. 11 How dispositions come about Dispositions Genetic endowmentExperience Habituation/ sensitisation: becoming less or more sensitive to repeated or ongoing stimuli Associative learning:habit formation, classical conditioning Explicit memory:images and thoughts recreated in response to cues

12. 12 The development of dispositions Critical periods: points where the chreods fork Deep chreods: small forces will not lead to escape; the system will settle back once they are removed; but if the system is on a cusp a small force will tip it into a new path Environmental forces Waddington’s epigenetic landscape

13. 13 Identity People differ in the propensity to think about ourselves, the nature of the thoughts and feelings that we have, and how consistent and coherent these are Identity is a very important source of motives; it is the foundation of personal norms that shape and set boundaries on our behaviour Identity refers to a disposition to generate particular thoughts and feelings about ourselves

14. 14 Self-control Self-control is a cornerstone of behaviour change. The moment-to-moment wants and needs arising from that must be strong enough to overcome impulses, wants and needs coming from other sources The exercise of self-control is effortful; it requires and uses up mental resources Self-control refers to wants and needs that arise from evaluations associated with our identity

15. 15 Addiction and dependence Addictions are activities that are given an unhealthy priority because of a disordered motivational system Dependence refers to the nature of that disorder. It varies from individual to individual and behaviour to behaviour

16. 16 Motivation to smoke Smoking Impulse to smoke Desire to smoke Need to smoke Positive evaluations of smoking Anticipated pleasure/ satisfaction Anticipated benefit Nicotine ‘hunger’ Unpleasant mood and physical symptoms Smoker ‘identity’ Beliefs about benefits of smoking Cues/triggers Reminders Nicotine dependence involves generation of acquired drive, withdrawal symptoms, strong desires from anticipated pleasure or satisfaction and direct simulation of impulses through associative learning Plan to smoke

17. 17 Motivation not to smoke Not smoking Inhibition Desire not to smoke Need not to smoke Positive evaluations of not smoking; negative evaluations of smoking Anticipated praise Anticipated self-respect Plan not to smoke Anticipated disgust, guilt or shame Fears about health Non-smoker ‘identity’ Beliefs about benefits of not smoking Cues/triggers Reminders Nicotine dependence probably also involves impairment of impulse control mechanisms undermining response inhibition

18. 18 What smokers say about stopping At any one time, when asked, most smokers report that they: –want to stop, citing health concerns as the main reason –intend to stop some time in the future –regret having ever started smoking –have tried to stop in the past –have tried nicotine replacement to help them stop –are trying to ‘cut down’ but a minority: –are ready to try to stop right now –are willing to see a stop smoking advisor or attend a stop smoking group

19. 19 Going beyond what smokers say Many smokers: –will respond positively to an offer of help with stopping who would not have done if they had been first asked whether they were interested in stopping –will suddenly stop without making any prior plans to do so –who say they plan to stop at a particular time or within a particular time window do not try to stop –who try to stop, will later fail to report that they tried to stop if that quit attempt does not last very long –misjudge what it is they find difficult about not smoking – focusing on the activity when in fact they are responding to a basic pharmacologically-driven need

20. 20 The process leading up to quit attempts: Motivational tension Smokers experience varying degrees of want or need (when it enters their consciousness) to ‘do something’ about their smoking That ‘motivational tension’ comes into and out of existence at varying levels of intensity

21. 21 The process leading up to quit attempts: Triggers Triggers put the idea of stopping in the mind of the smoker in such a way that the desire or need to change overwhelms motivation not to change The change is either adopted immediately or a plan is made to stop in the future

22. 22 Generating more quit attempts by increasing tension Motivational ‘tension’ Time Competing motivations Low level of motivationIncreased motivational ‘tension’ Change in internal or external environment Attempt

23. 23 Generating more quit attempts by reducing competing motivations Motivational ‘tension’ Time Competing motivations Attempt Reduced threshold

24. 24 Generating more quit attempts by creating more potential triggers Motivational ‘tension’ Time Competing motivations Increase in frequency of triggers More potential triggers Attempt

25. 25 Attempts to stop smoking These are switches in ‘identity’ from ‘smoker’ to any of: –‘smoker attempting to stop’ –‘smoker trying not to smoke’ –‘would-be non-smoker’ –‘definite non-smoker’ etc.

26. 26 Identity and behaviour in smoking cessation Time Smoking Attempting to stop Not smoking Cigarettes Behaviour Identity

27. 27 Success of quit attempts The new identity must generate wants and needs that are powerful enough to counter impulses, wants and needs arising from the disposition to smoke whenever these arise As time passes, the impulses, wants and needs to smoke will usually decrease to some degree because of physiological ‘normalisation’ and so the degree of self-control required will diminish However, habituation will often also decrease the wants and needs not to smoke

28. 28 Motivation to smoke during a quit attempt Day 1Day 2Day 5Day 10Day 20 Lapses Action threshold (restraint, competing motives) Impulse to smoke

29. 29 Causes of relapse: same day Same-day relapse is most often a result of the new identity being too unstable to withstand the relatively modest wants and needs to smoke arising from pharmacological dependence and/or social situations But it can arise from powerful pharmacological impulses, want or needs or instabilities in the system or events that precipitate heightened wants, needs or impulses

30. 30 Relapse: Early weeks Relapse in the early weeks is most often a result of strong wants and needs arising from pharmacological dependence with social and other motives superimposed on this But it can result from instabilities in the system, ‘moments of weakness’, low levels of motivational resources required to exercise self- control, persistence of wants or needs to smoke that deplete motivational resources, or events that precipitate acute wants, needs or impulses.

31. 31 Relapse: Late Late relapse is most often a result of a failure of the new identity to achieve sufficient stability at all times to overpower the momentary motives to smoke Over an extended period the chances of even a relatively modest motivation to smoke failing to provoke sufficient self-control is quite high For some smokers, the wants and needs to smoke do not diminish sufficiently, either because of continued positive evaluations of smoking, attachment to a smoker identity, continued pharmacologically based needs, or a failure for the learned habit to weaken

32. 32 Brief interventions Interventions should:  induce a feeling of desire to change  translate that into an impulse to initiate a change before it dissipates  create a lasting commitment to the change based on a shift of identity  trigger supporting activities that can maintain low levels of motivation to smoke and high levels of motivation not to

33. 33 Treatment to aid cessation The goal: –make sure that any impulse to smoke is overpowered an inhibitory force Medication can reduce the drive to smoke and possibly acute stimulus-driven impulses arising from simple pharmacological needs and habits The goal of psychological treatment is to manage the rest of the motivational system –minimise impulses, wants, needs and evaluations promoting smoking –maximise wants, needs and evaluations inhibiting smoking

34. 34 Minimising motivation to smoke Advise on minimising exposure to smoking triggers and maximise ‘effort to smoke’ Find out about and undermine smoker identity Find out about and undermine positive evaluations about smoking Advise on/train mental and physical activities that minimise the need to smoke Advise on/train mental and physical activities that distract attention from the need to smoke

35. 35 Maximising motivation not to smoke Generate social pressure not to smoke Advise on/train methods of triggering negative feelings about smoking Foster a strong non-smoker identity Foster a strong ‘in control’ identity Advise on how to trigger that identity in tempting situations

36. 36 Conclusions 1.When asked, most smokers report that they want to stop but few are ready to stop at any given moment and even fewer are willing to seek help 2.But most smokers are not thinking about stopping for most of the time 3.Human motivation is highly responsive to the immediate situation and interventions can capitalise on this to generate the desire to stop and trigger the impulse to make a quit attempt 4.The 3 Ts strategy provides a potential framework for promoting cessation: Tension Triggers Treatment