Why do people smoke and find it so hard to stop

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Why do people smoke and find it so hard to stop?
Robert West

• University College London
• November 2008

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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?

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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

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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

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The requirement

• To develop a model that describes how different
  types of motivation interact and compete to
  generate responses in the moment

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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)

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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
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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

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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

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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

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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

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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

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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

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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

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

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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

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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