1. 1 The PRIME theory of motivation and its application to smoking/smoking cessation University College London November 2008 Robert West

2. 2 Outline 1.What motivates behaviour generally? 2.Why do people smoke? 3.What is a quit attempt? 4.Why is it hard to stop smoking? 5.What does this mean for interventions?

3. 3 What motivates behaviour generally? We: –act on impulse we do it without thinking about the consequences –want or need something we seek a source of pleasure or satisfaction, or of relief –think it is right or will serve a purpose we do what we consider best –are following a plan we act on a prior intention And this motivation is stronger than any competing motivation present at the time

4. 4 Example Faced with an apparent thief running towards us on the street: –the impulse is to avoid physical contact (‘flinch’) –there may be anticipation of satisfaction from catching a criminal –there may be anticipation of harm from being attacked –there may be a belief that one should be a good citizen –there may be a prior generalised intention to fight crime where possible Conflict between these different types of motivation will determine what action is taken ‘in the moment’

5. 5 The requirement To develop a model that describes how different types of motivation interact and compete to generate responses ‘in the moment’

6. 6 A solution A motivational system with 5 levels, with higher levels feeding into lower levels –Responses starting, stopping or modifying actions –Impulses vs inhibition Activation of CNS pathways underpinning actions, and competing pathways inhibiting them (urges) –Motives Mental representations of future world states with feelings of anticipated pleasure or satisfaction (wants) or relief (needs) –Evaluations Beliefs involving sense of what is useful/harmful (functional), right/wrong (moral), pleasing/displeasing (aesthetic) –Plans Mental representations of future actions associated with feeling of varying degrees of commitment (intentions and rules)

7. 7 The structure of the motivational system p Plans r Responses i Impulses m Motives e Evaluations Five interacting subsystems providing varying levels of flexibility and requiring varying levels of mental resources and time Higher level subsystems have to act through lower level ones where they compete with direct influences on these

8. 8 Wants, needs and ‘oughts’ Many wants and needs arise directly from expectations of pleasure, satisfaction or relief Some arise from evaluations, e.g. what is morally right Wants and needs that arise purely from evaluations can be labelled ‘oughts’ –Eg. I ought to stop because it is harming my health When asked about ‘wants’ and ‘oughts’ together people will use ‘ought’ primarily to reflect their evaluations – not their wants and needs – these will then have only a weak association with behaviour

9. 9 Key points 1.Our behaviour is motivated at multiple levels from impulses, motives and evaluations to plans 2.Impulses and motives are highly reactive to the immediate situation 3.Higher level motivations must work through lower level ones where they may come into conflict with other motivations at that level 4.Plans have a vital role to play in organising our behaviour and protecting our longer term interests in the face of immediate demands 5.But implementing them in the face of conflicting wants, needs and urges is effortful and uses up mental resources

10. 10 Why do people smoke? They light up and puff on impulse –much smoking is ‘habitual’, done without thinking They want or need to –they expect to enjoy it; they experience a ‘hunger’ for a cigarette after a period of not smoking They think it serves a purpose –they expect it to help with stress, weight control and concentration They form plans to smoke –they have a routine of going for a cigarette during coffee breaks These motivations are stronger than any competing motivations including a plan not to smoke

11. 11 How does this arise? Nicotine ‘hits’ from each puff of a cigarette binds to nicotinic acetylcholine receptors in the brain causing: –dopamine release in the nucleus accumbens which: generates an automatic impulse to smoke in the presence of smoking cues provides pleasure and satisfaction associated with smoking makes other experiences associated with smoking more pleasurable changes the functioning of the brain region concerned so that when CNS nicotine levels are depleted there is need to smoke to restore those levels (nicotine hunger) –other chronic changes to brain chemistry resulting in adverse mood and physical symptoms such as anger, depression and difficulty concentrating generate an additional need to smoke

12. 12 What is an attempt to stop doing something? Self-consciously stopping doing something typically means: 1.forming a rule (plan) not to do it, or 2.forming a rule (plan) that one will ‘try’ not to do it Applying that rule in relevant situations which generates a want or need not to do it

13. 13 What is a quit attempt? Making ‘a serious attempt to stop smoking for good’ May involve: –‘trying not to smoke’ –‘not smoking’ May be*: –gradual (41%) or abrupt (59%) –planned (41%) or unplanned (59%) –aided (52%) or unaided (48%) *Data from Smoking Toolkit Study

14. 14 Rates of attempts to stop smoking Rate of attempts to stop decreases with age No difference by social grade Slightly more women try to stop than men Data from Smoking Toolkit Study

15. 15 ‘Wants’ and ‘oughts’ to stop smoking 3173 adult cigarette smokers in the Smoking Toolkit Study Allowed to endorse either or both of –I want to stop smoking –I ought to stop smoking Reports of ‘want’ to stop are lower than seen when asked on its own In multiple logistic regression, only ‘want’ is associated with quit attempts

16. 16 Why is it so hard to stop doing anything? To stop ourselves doing something that is habitual or we want or need to do, our rule must generate more powerful competing wants and needs This is difficult if: –the impulse, want or need to engage in the behaviour is at least sometimes strong and/or –our capacity to generate competing wants or needs when required is weak

17. 17 Why is it so hard to stop smoking? The impulse to smoke –Many smokers experience powerful cue-driven impulses in situations in which they would normally smoke The want to smoke –Many smokers enjoy and get satisfaction from smoking The need to smoke –‘Nicotine hunger’, adverse effects of abstinence Positive beliefs about smoking –Stress relief, aid to concentration, weight control The routine of smoking –Strong embedded plans to smoke at certain times

18. 18 Success rates of unaided quit attempts The need to smoke decreases rapidly after the first week, but can re-emerge months or years later

19. 19 Wanting and needing to smoke Wanting to smoke appears to deter attempts to stop while needing to smoke leads to relapse once an attempt is made Data from 1479 smokers in Smoking Toolkit Study, followed up 6 months after ratings or enjoyment and urges were made to find out whether: had attempted to stop and if so had relapsed

20. 20 Tackling the problem at all levels: reducing motivation to smoke Reduce the impulse –medication during smoking to break the smoking-reward link –reduce exposure to smoking cues Reduce the want and need –medication during smoking and abstinence to make smoking less satisfying and reduce nicotine hunger and adverse symptoms –control exposure to events that provoke wanting and needing Change beliefs –convince smokers that smoking does not confer benefits Change plans –change routines that involve smoking

21. 21 Tackling the problem at all levels: increasing motivation not to smoke Generate competing impulses –set up competing habitual responses to smoking cues –expose to cues generating impulse to make quit attempt Increase the want and need not smoke –use extrinsic rewards and punishments (e.g. social approval, disapproval, vouchers) –maintain salience of negative feelings about smoking (e.g, disgust, anxiety) –foster intrinsic rewards for not smoking (e.g. achievement) Change beliefs –foster negative beliefs about smoking and positive non-smoker identity Establish firm, coherent plans –Establish clear ‘not a puff’ rule as part of new identity –Establish clear if-then rules for actions that minimise wants, needs and urges

22. 22 Tackling the problem: maximising self- regulatory capacity Applying the no-smoking rule in the face of conflicting wants, needs and urges requires and depletes mental energy Potential solutions: –Time quit attempts to periods when mental energy is high –Address external factors that may deplete mental energy –Establish rule with very clear firm boundaries - personal smoke-free zone/smoking is not an option

23. 23 Conclusions 1.Our actions are controlled by multiple levels of a motivational system (PRIME) with higher levels (plans) having to work through lower levels (impulses and inhibitions) 2.At every moment there may be conflict between motivations arising from the same or different levels 3.Stopping doing something involves forming a rule (plan) which has to generate sufficiently strong wants and needs to overpower more immediate wants, needs and urges rising at a lower level 4.Stopping smoking is hard because of powerful urges, wants and needs arising from the actions of nicotine in the brain 5.The optimum solution requires attending to all levels of the motivational system to minimise the motivation to smoke and maximise the motivation not to at all times

24. 24 Conclusions Some important outcomes (in addition to standard guidance) –offer help with stopping to all smokers –maximise opportunities to take action to stop at all times –be ready to help with unplanned quit attempts –where possible foster a strong, deep commitment to an absolute no-smoking rule –in smokers not ready to stop recommend medication to reduce satisfaction from smoking

25. 25 Thank you for your attention www.primetheory.com