University College London May 2010

1. Successful behaviour change involves changing what people want or need 'in the moment', not just what they intend or think is good Robert West University College London May 2010

2. Outline • Part 1: concepts and theory • Behaviour as part of a system • Behaviour-change goals vs behaviour • The behaviour change wheel • The structure of motivation: PRIME Theory • Part 2: Data • Predicting attempts to stop smoking • Predicting success of quit attempts • Discovering effective behaviour change techniques to aid smoking cessation

3. The ‘behaviour system’ • Behaviour emerges from interactions between • Capability • what an individual is physically or mentally capable of • Motivation • the values, desires, habits and instincts that influence behaviour • Opportunity • the environmental circumstances that determine the physical/psychological availability of a behaviour

4. The ‘behaviour system’ Capability Behaviour Motivation Opportunity

5. The ‘behaviour system’ and behaviour change Capability Physical and mental ability: changeable by education, training, enablement/resources Behaviour Motivation Values, desires and habits: changeable by education, persuasion, inducement, punishment, environmental restructuring Opportunity Physical and psychological/social availability: changeable by restrictions, education, persuasion, enablement/resources, environmental restructuring

6. When ‘motivation’ becomes ‘capability’ • Mr X ‘wants’ to stop smoking but ‘cannot’ • The desire of Mr X to ‘be a non-smoker’ is prevented by his momentary desires to ‘smoke a cigarette’ • So he is incapable of stopping smoking because his desire to smoke on each occasion is stronger than his desire to be a non-smoker

7. Behaviour-change goal versus behaviour • The key is the distinction between the two targets of the motivation • Becoming a non-smoker: the ‘behaviour-change goal’ • Smoking a cigarette: the behaviour itself

8. Implications • Successfully promoting deliberate behaviour change involves • Getting individuals to be sufficiently motivated to set the behaviour-change goal • Making changes in whatever parts of the behaviour system are most effective in causing momentary motivation relating to the new behaviour to exceed that relating to the old behaviour

9. The behaviour change wheel • A method for • describing systems in which policies, interventions and behaviour interact • designing interventions and policies starting with an understanding of the relevant behaviour system • evaluating the likely effects and side-effects of existing or proposed policies • Based on categories of interventions and policies that • are mutually exclusive • provide comprehensive coverage • are specified at the same conceptual level

10. Physical Capability Emot/ Habit Psych Motivation Psych/social Evaluat-ion Physical Opportunity The Behaviour Change Wheel Behavioural system Service provision Intervention system Regulation Training Education Policy system Fiscal Restriction Persuasion Environmental/ social planning Coercion Inducement (incentives/rewards) Legislation Environmental restructuring Enablement/ resources Guidelines Mass media Michie & West, 2010

11. The motivational system • Understanding the ‘motivational system’ • should help in determining where to focus efforts in developing behaviour change interventions • promoting the behaviour-change goal • helping to keep the behaviour in line with that goal

12. The structure of human motivation

13. The structure of human motivation Lighting up a cigarette Taking a puff on a cigarette Saying no to offer of a cigarette • Starting, stopping or modifying actions • Generated by the strongest of competing impulses and inhibitions at that moment

14. The structure of human motivation • Impulses and inhibitions: patterns of activation in CNS pathways that organise and impel or block specific actions • Formed from strongest of competing learned and unlearned stimulus-impulse associations • Motives are important triggering stimuli • Impulses are experienced as urges when blocked • Vary in strength Impulse to light up a cigarette Inhibition of impulse to light up

15. The structure of human motivation Want to smoke Need a cigarette Want to stop smoking • Feelings of desire or attraction or repulsion in relation to something that is imagined • Want: anticipated pleasure or satisfaction • Need: anticipated relief from mental or physical discomfort • Formed when stimulus generates image to which past experience has associated positive or negative feelings • Can vary in strength

16. The structure of human motivation • Beliefs (internalised statements) that something is good or bad • Formed from acceptance of communication or when stimulus triggers recall of plans, memory of beliefs, plans, wants and needs, or inference • Must generate motive (want or need) to influence behaviour • Can vary in strength of adherence, ambivalence, extremity, valence Smoking is harming my health and costing me a lot of money I ought to stop smoking

17. The structure of human motivation • Self-conscious intentions to behave in a particular way (personal rule) or perform an action (one-off plan) in the future • Formed when positive evaluation of action outweighs negative one • Must be remembered and generate positive evaluation to be enacted • Can vary in: commitment, starting conditions, specificity One off: I will stop smoking tomorrow Personal rule: I will not smoke

18. The control of purposeful behaviour • We act in pursuit of what we most desire (want or need) at every moment • Wants and needs are distinguishable from each other and from ‘oughts’ (beliefs about what one should do) and intentions (what one plans to do)

19. Motivation to make an attempt to stop smoking • Motivation to make a quit attempt may arise from wants or needs which may act independently of intentions • Oughts would not be expected to play a role unless they create wants or needs

20. Smoking Toolkit Study • Household survey of representative sample of English smokers aged 16+ • Follow-up at 3 months by postal questionnaire • Sample size followed up >2,000 • ‘Which of the following applies to you. Tick any that apply’ • I want to stop smoking • I need to stop smoking • I ought to stop smoking • I intend to stop smoking soon

21. Motivation to stop smoking

22. Association between elements of motivation to stop smoking Tetrachoric correlations, p<0.001 in all cases

23. Motivation to stop smoking predicting quit attempts 3 months later ** ** ** Results of multiple logistic regression with all predictors entered together: p<0.05 in all cases

24. Conclusions • It is useful to distinguish between want, need, intend and ought to quit • Want, need and ought are moderately correlated with each other • Intend is correlated more highly with want than ought or need • Prediction of quit attempts • Want and intend to quit contribute positively • Ought to quit contributes negatively • Need to quit does not contribute

25. Motivation elements predicting quit attempts 3 months later

26. Motivation elements and quit attempts • Quit attempts are equally predicted by want and intend and their combination • Ought on its own has no impact but has a mitigating effect on want and intend

27. Composite motivation scale predicting quit attempts at 3-month follow up

28. Motivation to smoke • Motivation to smoke may involve both wants (arising out of enjoyment) and needs (arising out of nicotine-induced ‘drive’ to smoke) • Relapse to smoking following a quit attempt may arise from either of these

29. Enjoyment, urges to smoke and relapse to smoking *** Urges N=1009 p<0.001, enjoyment N=785, p=ns

30. Motivation to smoke and relapse • Enjoyment (want) does not predict relapse but urge to smoke (need) does

31. Helping smokers to stop • Behaviour change techniques (BCTs) used by the English Stop Smoking Services • 43 BCTs • Address motivation in different ways • directly influencing desire to smoke or not to smoke • maximise self-regulatory capacity • promote adjuvant activities • supporting other BCTs

32. Classification of BCTs by function BCTs Focus on specific behaviour Address motivation Maximise self-regulation Promote adjuvant activities General aspects of interaction intervention content that directly promotes abstinence maximise motivation to abstain or minimise motivation to smoke intervention content that promotes activities that indirectly facilitate abstinence promote mental and physical activities that either reduce exposure to motivation to smoke or help with resisting that motivation competences necessary for effective delivery of specific BCTs and adjuvant activities

33. Associations between specific BCTs and success rates of stop smoking services • 37 Stop smoking Services • 177,000 smokers • Examined associations between references to BCTs in manuals and 4-week success rates

34. BCTs emphasised in treatment manuals of more effective services • Address motivation • Strengthen ex-smoker identity • Provide rewards on stopping smoking • Measure CO • Maximise self-regulatory capacity and skills • Facilitate relapse prevention and coping • Advise on changing routine • Promote adjuvant activities • Advise on stop-smoking medication • Ask about experiences of stop smoking medication • General • Elicit client views • Give options for additional and later support 34

35. Conclusions • Understanding the ‘behaviour system’ helps to identify levers of change and provides a focus for developing interventions and policies • Understanding the motivational system promotes potentially useful distinctions between different sources of motivation and a focus on momentary wants and needs • In smoking cessation: • wants and intentions promote quit attempts while needs and ‘oughts’ do not • need to smoke promotes relapse while wanting to smoke does not • behaviour change techniques associated with successful treatment can all be accommodated within the framework of influencing momentary wants and needs