1. Why do people smoke and find it so hard to stop?
Robert West
University College London
November 2008

2. Outline Why do people do anything? Why do people smoke?
What does stopping doing something mean?
Why is it hard to stop doing anything?
Why is it hard to stop smoking?

3. Why do people do anything?
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. 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. The requirement
To develop a model that describes how different types of motivation interact and compete to generate responses ‘in the moment’

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

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

9. 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

10. 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

11. What does stopping doing something mean?
Self-consciously stopping doing something typically means:
forming a rule (plan) not to do it, or
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

12. 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

13. 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 over-learned plans to smoke at certain times

14. Rates of attempting to stop smoking
Rate of attempts to stop decreases with age
Data from 4374 adults aged 16+ who smoked in the past year in Smoking Toolkit Study, surveyed in 2008

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

16. 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

17. 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

18. Tackling the problem at all levels: increasing motivation not to smoke
Generate competing impulses
set up competing habitual responses to smoking cues
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 to minimise wants, needs and urges

19. Conclusions
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)
At every moment there may be conflict between motivations arising from the same or different levels
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
Stopping smoking is hard because of powerful urges, wants and needs arising from the actions of nicotine in the brain
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