1. Using theory to design better tobacco control interventions
Robert West
University College London
September 2011

2. Statement of competing interests
I undertake research and consultancy for companies that develop and manufacture smoking cessation medications
I have a share of a patent in a novel nicotine delivery device
I am co-director of the NHS Centre for Smoking Cessation and Training
I am a trustee of QUIT and on the scientific advisory board of Free & Clear

3. Topics What is tobacco control? The MPOWER approach
The COM-B model of behaviour
The Behaviour Change Wheel as a system for developing an intervention strategy
Applying COM-B and the BCW to tobacco control

4. Tobacco control

5. A useful heuristic: need guidance on implementation
MPOWER
Monitor tobacco use and prevention policies
Protect people from tobacco smoke
Offer help to quit tobacco use
Warn about the dangers of tobacco
Enforce bans on tobacco advertising, promotion and sponsorship
Raise taxes on tobacco
A useful heuristic: need guidance on implementation

6. Tobacco control as ‘behaviour change’
Tobacco use is a form of behaviour
The goal is to achieve sustained ‘behaviour change’
prevention of tobacco uptake
tobacco cessation
changes in use of tobacco products
Models of behaviour change should provide a scientific basis for developing intervention strategies

7. Why theories are important
One can build a simple bridge on the basis of what seems intuitively sensible (an implicit commonsense model) and trial and error
But to build increasingly better bridges spanning longer distances and carrying heavier loads one needs an incremental technology based on theory

8. Theories of behaviour change
There is a rich body of theory in behaviour change. For example ...
Decision theory
how people assess risk and make choices
Learning theory
how experiences of reward and punishment control our behaviour
Personality theory
How people differ and why
Economic theory
how changes in price and availability affect behaviour
Social theory
how members of groups interact
Neurobiological theories
brain mechanisms underlying change

9. Models to be considered
COM-B model of behaviour in context
an overarching model of behaviour and what is needed to achieve behaviour change
PRIME Theory of motivation
a theory of motivation with particular emphasis on developing behaviour change interventions
The Behaviour Change Wheel
a system for developing theory- and evidence-based behaviour change interventions from COM-B and PRIME

10. Why these models?
They
bring together core components of other theories into a single coherent model
stay as close as possible to everyday language
are specifically aimed at developing behaviour change interventions
Key references:
Michie S, M van Stralan, West R (2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42.
West R (2011) Models of Addiction. Lisbon: EMCDDA

11. Not a replacement for specific theories
A skeleton on which to put the flesh of specific theories so that they work together
Learning theory
Neurobiological theories
Decision theory
Personality theory
Economic theories
Social theories

12. COM-B system for analysing behaviour in context
Capability, motivation and opportunity all need to be present for a behaviour to occur
They all interact as part of a system
Motivation must be stronger for the target behaviour than competing behaviours

13. Capability
The person has to be physically and psychologically able to perform the behaviour
Psychological capability
knowledge and understanding of
why it could be worth doing it
how to do it
capacity and skills for self-regulation
impulse control
mental energy
how to make effective plans
how to structure the environment

14. Motivation
The person has to want or need to engage in the behaviour at relevant moments more than they want to do something else or not do it
Sources of motivation
Reflective thought
Evaluation of costs and benefits
Self-conscious plans
Feelings and urges
Wants: anticipated pleasure or satisfaction
Needs: anticipated relief from mental or physical discomfort
Impulses: Habit and instinct
Counter-impulses: inhibitory processes

15. Opportunity
There have to be events and situations in the social and physical environment that enable or prompt the behaviour
Physical environment
enabling factors
cues/prompts
Social environment
modes of thinking/language
models

16. Motivation: reflective and automatic
Beliefs about what is good and bad, conscious intentions, decisions and plans
Reflective
Automatic
Emotional responses, desires and habits resulting from associative learning and physiological states

17. The rider and the elephant
The rider (our self-conscious reasoning processes) has to communicate with and influence the elephant to get anything done
The elephant (our emotional and impulsive processes) has its own desires which may conflict with those of the rider
Haidt J (2006) The happiness Hypothesis

18. PRIME Theory: reflective and automatic processes

19. PRIME Theory: the structure of human motivation
I will try not to smoke
Smoking is bad for me
Need a cigarette
Urge to smoke

20. PRIME Theory: Change processes
Automatic
Perception: acquiring information from the senses
Associative learning: operant and classical conditioning
Maturation: changes associated with growing older
Habituation: decrease in response with exposure
Sensitisation: increase in response with exposure
Imitation: direct copying
Identification: forming one’s own identity from perceptions of others
Consistency disposition: generation of motives, ideas from similar ones
Dissonance avoidance: negating or blocking uncomfortable beliefs
Objectification: generating evaluations from likes and dislikes
Chemical ‘insult’: pharmacological responses
Physical ‘insult’: brain lesions
Reflective
Assimilation: acquiring information via communication
Inference: induction and deduction
Analysis: formal and informal calculation
Long-term changes to the operation of the motivational system can come about through many elementary processes.
Many of these involve no reflective processes (e.g. maturation, perception).
Others involve reflective though: assimilation of communicated ideas, inference and analysis.

21. The Behaviour Change Wheel: hub

22. Intervention functions (EPICTREME)
Education
Increasing knowledge or understanding
Persuasion
Using communication to induce positive or negative feelings or stimulate action
Incentivisation
Creating expectation of reward
Coercion
Creating expectation of punishment or cost
Training
Imparting skills
Restriction
Using rules that limit engagement in the target behaviour or competing or supporting behaviour
Environmental restructuring
Changing the physical or social context
Modelling
Providing an example for people to aspire to or imitate
Enablement
Increasing means/reducing barriers to increase capability or opportunity

23. Behaviour Change Wheel: inner ring

24. Linking COM-B to intervention functionsEd P I C T R
Env M
Ena
CPh
CPs
OPh
OSo MA MR

25. Examples: Promoting smoking cessation
C: Lack of knowledge of why or how to stop smoking
Education
C: Capacity for self-control overpowered by drive to smoke
Enablement
M: Lack of concern about effects of smoking on self or others
Persuasion, Incentivisation, Coercion
M: Liking being ‘a smoker’
Persuasion
O: Frequent exposure to prompts to smoke
Environmental restructuring
O: Ability to smoke anywhere
Restriction

26. Policy options
Communication/ marketing Using print, electronic, telephonic or broadcast media
Guidelines Creating documents that recommend or mandate practice. This includes all changes to service provision
Fiscal Using the tax system to reduce or increase the financial cost
Regulation Establishing rules or principles of behaviour or practice
Legislation Making or changing laws
Environmental/ social planning Designing and/or controlling the physical or social environment
Service provision Delivering a service

27. Behaviour Change Wheel: complete

28. Education as part of tobacco control
Increasing knowledge and understanding about tobacco use and cessation
effect on life-expectancy
effect on pain and disability
effect on mental health
consequences of use of different forms of tobacco
importance of stopping as young as possible
effect on other people
tobacco industry tactics
best ways of stopping
Targeting evaluations

29. Persuasion as part of tobacco control
Changing the way people feel about tobacco use
reminding of importance of stopping smoking
associating smoking with negative imagery
creating positive imagery around not smoking
making effective methods of stopping attractive
countering tobacco company promotion
Targeting evaluations, emotion and impulse/inhibition

30. Incentivisation as part of tobacco control
Giving people rewards for not smoking
rewards for not taking up smoking
rewards for abstinence
rewards for use of effective methods of achieving abstinence
Targeting evaluations, emotion, impulse/inhibition

31. Coercion as part of tobacco control
Punishing smoking
raising taxes
combating illicit supply
stigmatising smoking
Targeting evaluations, emotion, impulse/inhibition

32. Training as part of tobacco control
Providing people with the skills to avoid or escape from tobacco use
refusal skills training
self-control training
training in effective use of cessation methods
Targeting capability

33. Restriction as part of tobacco control
Making rules about what, when and where people can smoke
banning high-tar cigarettes
banning smoking in indoor public areas
banning smoking in cars with children in
Targeting opportunity

34. Environmental restructuring as part of tobacco control
Restricting availability
removing vending machines
reducing outlet density
preventing sales to minors
Reducing smoking prompts
Reducing tobacco promotion
Reducing exposure to smoking in films etc
Targeting opportunity

35. Modelling as part of tobacco control
Showing people attractive non-smoking models
refusing to smoke
stopping smoking
using effective cessation methods
Targeting evaluations, emotion, impulse/inhibition

36. Enablement as part of tobacco control
Helping people resist or stop smoking
addressing psychological problems that pre-dispose to smoking
providing medicines to combat craving and withdrawal symptoms, block nicotine’s effects and substitute for positive functions
providing non-pharmacological substitutes for smoking
providing behavioural support to aid cessation
Targeting capability

37. Other key considerations
Affordability
What can be afforded within the resources that can be devoted to it
Practicability
What is the best implementation that can be achieved
Acceptability
What is ethically and publicly acceptable

38. Understanding the context
Need the best, most specific information possible
Use this in the COM-B analysis to help decide the strategy

39. Relevant evidence from the UK
Education:
quitting younger, better use of NRT bought OTC, and more use of Stop Smoking Services
Persuasion:
more effective use of GP advice
Coercion:
more effective use of cost increases
Restriction:
examine how to make them work better
Enablement
Raise the quality and increase affordability of Stop-Smoking support
Arnott D (Ed) All Party Parliamentary Group Report on Tobacco Control in England. London: ASH

40. Education

41. Percentage of ever regular smokers who have quit for at least a year
Green Line: A-C1; Blue Line: C2-E, Red Line: All
Plateau in quitting at the crucial point in lifespan
Smoking Toolkit Study:

42. Specialist Stop Smoking Services give the best results
Significantly better than no aid adjusting for confounding variables, p<0.001
Data from based on smokers who tried to stop in the past year who report still not smoking at the survey adjusting for other predictors of success (age, dependence, time since quit attempt, social grade, recent prior quit attempts, abrupt vs gradual cessation): N=7,939

43. But only used by a tiny minority of smokers
Smoking Toolkit Study:

44. Little evidence for benefit of OTC NRT as currently used
Data from based on smokers who tried to stop in the past year who report still not smoking at the survey adjusting for other predictors of success (age, dependence, time since quit attempt, social grade, recent prior quit attempts, abrupt vs gradual cessation): N=7,939

45. Use of aids to cessation
Smoking Toolkit Study:

46. Persuasion

47. Attempts to stop according to GP advice to stop smoking
N=7611, p<0.001 for difference between offer of support/prescription and others
Smoking Toolkit Study:

48. GP advice to stop smoking
Percentage of smokers and recent ex-smokers for whom …; data from Smoking Toolkit Study, N=7611

49. Use of aids to stop according to GP advice to stop smoking
Offer of help is associated with greater use of prescription meds
N=2714, p<0.001 for difference in use of aids
Smoking Toolkit Study:

50. Association between smoking motives and attempts to quit in the past year
Main barriers to quitting
are identity and enjoyment
Final model from forward stepwise logistic regression of attempt to stop in past 12 months on to beliefs about smoking. Odds ratios less than 1 represent negative associations. N=3033
Smoking Toolkit Study:

51. Coercion

52. Key pieces of evidence from the Smoking Toolkit Study: cost of smoking
Increased cost of smoking can translate to reduced consumption but no increase in toxin intake or quit attempts
N=10,920 smokers; includes hand-rolled; p<0.001 for increased cost per cigarette, decrease in cigarette consumption, and decrease in quit attempts
Smoking Toolkit Study:

53. Restriction

54. Smoking prevalence before ‘smoke-free’ implementation
Pre- smoke-free, smoking prevalence was declining at an estimated rate of 0.165% per month

55. Smoking prevalence immediately after ‘smoke-free’
In the 8 months post smoke-free the rate of decline in prevalence increased to 0.72% per month.

56. Smoking prevalence post-recession
At the ‘official’ start of the recession there was an upturn in prevalence and since then prevalence has been declining very slowly at 0.046% per month.

57. Smoking prevalence 2007-2010: social grade A-C1
The pattern of decline pre-smoke-free, post-smoke-free and post-recession was observed in social grades A to C1
A-C1: professional to clerical
C2-E: skilled manual to long-term unemployed

58. Smoking prevalence 2007-2010: social grade C2-E
This pattern was also observed in social grades C2-E, except that post recession the decline in this group has been faster than in social grades A-C1.

59. Association between motives to stop smoking and attempts to quit in the past year
Potential negative impact
of restrictions on motivation to stop
Final model from forward stepwise logistic regression of attempt to stop in past 12 months on to beliefs about smoking. Odds ratios less than 1 represent negative associations. N=5647

60. Quit attempts pre- and post- smoking ban
Attempts to stop smoking were not higher post-ban
Overall, the period following smoke-free was associated with a reduction in the rate of quit attempts, so the decline in prevalence cannot be attributed to this.
Base: smoked in last year; p<.05 for decline;

61. Success of quit attempts pre- and post-smoking ban
Attempts to stop smoking were more successful post-ban
There was an increase in the success rates of quit attempts following smoke-free so this seems likely to be the cause of the decline in prevalence at that time.
Base: made quit attempt in last month; p<.05 for increase post-smoke-free;

62. Enablement

63. Performance of the NHS Stop Smoking Services varies considerably
Negative impact means less than 25% CO-verified success rate
Impact=Number of 4-week, CO-verified quitters generated above what would have been expected from medication alone (25% success rate) per 100,000 adult population: Data from Information Centre

64. Medication options used
CO-validated 4-week abstinencea
OR (95% CI)
p value
Medication
Single NRT vs no medication
1.75 ( )
<0.001
Combination NRT vs single NRT
1.42 ( )
0.019
Bupropion (Zyban) vs single NRT
1.12 ( )
0.160
Varenicline (Champix) vs single NRT
1.78 ( )
Brose L, West R, McDermott M, Fidler J, Croghan E, McEwen A (In Press) What makes for an effective stop-smoking service? Thorax.

65. CO-validated 4-week abstinencea
Treatment type
CO-validated 4-week abstinencea
OR (95% CI)
p value
Intervention type (reference: one-to-one)
Closed group
1.43 ( )
0.001
Drop-in
0.72 ( )
0.003
Open (rolling) group
1.46 ( )
<0.001
Telephone support* -
Other
0.97 ( )
0.851
Brose L, West R, McDermott M, Fidler J, Croghan E, McEwen A (In Press) What makes for an effective stop-smoking service? Thorax.

66. CO-validated 4-week abstinencea
Treatment setting
CO-validated 4-week abstinencea
OR (95% CI)
p value
Intervention setting (reference: Specialist clinics)
Primary care
0.80 ( )
0.037
Pharmacy
0.94 ( )
0.303
Other
0.87 ( )
0.239
Brose L, West R, McDermott M, Fidler J, Croghan E, McEwen A (In Press) What makes for an effective stop-smoking service? Thorax.

67. A narrative for England: the back story
Smoking is still killing 80,000 people each year.
There is strong support for interventions that support smokers to stop and protect children. They also must give value for money.

68. A narrative for England: the plot
We can make better use of existing resources to support smokers in stopping and protect children from starting and from effects of smoking
Communications
how best to stop, better use of NRT, linked to price increases and tighter control on illicit supply
importance of trying to stop at least once a year, starting as young as possible
Health professional advice
very brief advice just on best methods of stopping and offer of support
Tobacco industry
remove all possible methods of promoting their products (point of sale, plain packaging)
Extending restrictions
with consent as a means of supporting quitting and protecting young people
Stop Smoking Services
Get better value by improving quality

69. Conclusions
Need an overarching model of behaviour change to develop an ‘incremental technology’
COM-B, PRIME and BCW provide a possible approach – but only a small first step
Provides a systematic basis for developing an intervention strategy based on an analysis of what is needed to achieve a behavioural target
Specific evidence of the behaviour in context is then needed to examine priorities and details of the interventions

70. The elephant, the rider and the bridge!