Robert West 2014

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Enhancing motivation to stop smoking:

from theory to practice

University College London

August 2014

Robert West

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Declaration of interests

• I undertake research and

consultancy for companies that

develop and manufacture

smoking cessation medications

• I am a trustee of QUIT

• I am co-director of the NHS

Centre for Smoking Cessation

and Training

Aim

• To summarise the psychology of motivation

• To show how it can be applied to helping smokers to

stop

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4

Outline

1. What is motivation?

2. Motivation to smoke and motivation to stop

3. Implications for how we promote smoking cessation

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What is motivation?

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Definition of motivation

• All those brain processes that energise and direct our behaviour

• Includes:

– automatic impulses e.g. to puff on a cigarette

– desires e.g. wanting to stop smoking

– evaluations e.g. thinking that smoking is bad

– plans e.g. to stop smoking

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Where motivation fits in to understanding

behaviour: COM-B

1. Capability, motivation and opportunity all

need to be present for a behaviour to occur

2. They all interact as part of a system

3. Motivation must be stronger for the target

behaviour than competing behaviours

Michie S, M van Stralen, West R (2011) The

Behaviour Change Wheel: A new method for

characterising and designing behaviour change

interventions. Implementation Science, 6, 42.

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PRIME Theory: the structure of human motivation

www.primetheory.com

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www.primetheory.com

Impulse to reach for a

cigarette

10


www.primetheory.com

Feeling of wanting or

needing a cigarette

11


www.primetheory.com

Belief that smoking is

bad

12


www.primetheory.com

Plan to stop smoking

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Key statements about motivation

Identity (our thoughts,

images and feelings about

ourselves) are an important

source of wants and needs

At every moment we act in pursuit of what we most

want or need at that moment

We want things that we

imagine will give us pleasure

or satisfaction

We need things that we

imagine will give us relief

from mental or physical

discomfort

Beliefs about what is good or

bad, and prior intentions

have to work through

momentary wants and needs

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Motivation to smoke and motivation to

stop

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Motivation to smoke

• Cue-driven impulses to smoke

– caused by nicotine-induced release of dopamine in nucleus accumbens

• Wanting to smoke

– caused by enjoyment of pharmacological effects and social rewards

• Needing to smoke

– to relieve cravings and withdrawal symptoms

• Valuing smoking

– belief that it serves functions such as stress relief

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Motivation to smoke

www.primetheory.com

Cue-induced impulse

to smoke

Wanting and needing

smoke

Belief that smoking

helps with stress

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Motivation to stop smoking

• Wanting and needing to stop

– caused by worry about health effects, dissatisfaction with cost of smoking, concern about effects on family, dislike of being addicted

• Belief that ought to stop

– caused by acceptance of social disapproval of smoking, acknowledgement that smoking is harmful

• Intention to stop

– caused by wanting or needing to stop, or belief that ought to stop together with time imperative or opportunity

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Motivation to stop smoking

www.primetheory.com

Wanting/needing to

stop

Belief that smoking is

bad

Intention to stop

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Enjoyment and smoker identity are the main

barriers to trying to stop

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

I enjoy

smoking

I like being a

smoker

It keeps my

weight down

It helps me

cope with

stress

I get

unpleasant

symptoms

when cannot

smoke

I am addicted

to cigarettes

Od

ds r

atio

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

Main barriers to quitting

are identity and enjoyment

Smoking Toolkit Study:

www.smokinginengland.info

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Health concerns, cost and family are main

promoters of quit attempts

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Harming current

health

Harming future

health

Costing too

much

Worried about

effect on family

Getting difficult

to smoke

Od

ds r

atio

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


Main drivers of quitting

are worry about health,

cost and family

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Desire and intention predict quit attempts but

‘duty’ does not

0

0.5

1

1.5

2

2.5

I want to stop I intend to stop soon I am confident I can

stop

I ought to stop

Od

ds r

atio

Final model from forced entry logistic regression of attempt to stop in

subsequent 6 months from motivational measures. N=2483


p<0.01

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Desire and intention combined strongly

predict quit attempts

0

10

20

30

40

50

60

Really want

and intend

1m

Really want

and intend

3m

Want and

hope to

soon

Really want

but not

intend

Want but

not thought

when

Should Don't want

% tri

ed

to

sto

p in

pa

st 6

mo

nth

s a

t 6

m fo

llo

w u

p

N=2088, p<0.001 for linear trendsee www.smokinginengland.info

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Physician advice is the main external trigger

for quitting

0 5 10 15 20 25 30

Advice from health professional

Something said by family or friends

Knew someone who was stopping

Smoking restrictions

TV advertisement for NRT product

See a health warning on a cigarette packet

Government TV adverisement

Hearing about a new stop-smoking treatment

Percent

N=5514see www.smokinginengland.info

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Many quit attempts are unplanned and in

England use some form of help

0

10

20

30

40

50

60

70

80

90

100

Unplanned Used some form of aid

Pe

rce

nt w

ho

qu

it a

s s

oo

n a

s th

ey th

ey m

ad

e th

e

de

cis

ion

Health professionaladvice

Other triggers

N=5514; differences between HP

advice and other triggers all significant

at p<0.01see www.smokinginengland.info

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GP offer of support to smokers increases quit

attempts

0

10

20

30

40

50

60

70N

ot se

en

GP

Sm

okin

g n

ot

rais

ed

Me

ntio

ne

d

bu

t n

ot

ad

vis

ed

to

sto

p

Ad

vis

ed

to

sto

p b

ut n

o

offe

r

Pre

scri

ptio

n

on

ly

Re

co

mm

en

d

to s

ee

pra

ctice

nu

rse

Re

fer

to

SS

S

% tri

ed

to

sto

p in

pa

st ye

ar

N=7611, p<0.001 for difference between offer of support/prescription and others

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But only a minority of smokers in England receive

it

38%

20%

5%

11%

7%

8%

11%

Did not see GP

Saw GP but no mention of

smoking

Smoking mentioned but not

advised to stop

Advised to stop but not

offered help

Offered medication

Advised to see practice

nurse

Referred to Stop Smoking

Service

Percentage of smokers and recent ex-smokers for whom …; data

from Smoking Toolkit Study, N=7611

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Implications for promoting smoking

cessation

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Key principles for health professionals in

promoting smoking cessation: HELP!

• Help:

– Focus on how you can help with cessation rather than

advising or instructing them to stop

• Engage:

– Make sure patients understand that you will engage with

them as long as is needed until they are able to stop

permanently

• Listen:

– Listen carefully and respectfully to smokers’ concerns

about stopping and the possible treatment options, and

address them positively

• Provide:

– Provide smokers with whatever treatment options are

available with the highest proven impact, including

referral to specialist help where possible

H

E

L

P

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NCSCT Online training may increase effective

physician advice

• Online course taking 20 minutes to complete

• Training in Very Brief Advice (VBA) taking 30 seconds to deliver

• Focuses on offering help

www.ncsct.co.uk/vba

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• Physician advice is the single most important external

trigger to quit attempts

• Offer of help is the most important element of physician

advice

• HELP! captures key elements of physician advice on

smoking

• An online course can be a useful way of learning how to

deliver smoking cessation advice

Conclusions

www.ncsct.co.uk/vba

Robert West 2014

Education

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