1. 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.

2. 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

3. 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

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

5. 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:

6. 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

7. 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

8. 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.

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

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