Understanding, preventing and treating addiction to cigarettes through the lens of PRIME Theory

1
Understanding, preventing and treating addiction
to cigarettes through thelens of PRIME Theory
Robert West

• University College London
• February 2009

2
Outline

• Defining addiction and motivation
• Developing a theory of motivation
• Applying the theory to addiction to cigarettes

3
Outline

• Defining addiction and motivation
• Developing a theory of motivation
• Applying the theory to addiction to cigarettes

4
Addiction

• Individuals repeatedly experience powerful
  motivation to engage in particular maladaptive
  behaviours that often undermine and overwhelm
  motivation to exercise restraint
• Two elements
• strength of motivation
• capacity for restraint
• Degree of addiction can be measured by indices of
  the dominance of the motivation
• subjective reports or strength, persistence
  and/or frequency of urges
• observations of priority given to the behaviour

5
Motivation

• Not just reasons
• Brain processes that energise and direct
  behaviour
• Relevant concepts
• impulse
• drive
• want
• need
• goal
• choice
• intention

6
Where does motivation fit in?
Response control system
Skill
Skill
Skill
Skilled
Response control system
Response control system
Response control system
Skilled
Skilled
Skilled
Skill
Response generation system
Motivation
Motivation
Motivation
Motivation
Response generation system
Response generation system
Response generation system
Motivation
Motivation
Motivation
Motivation
Cognitive system
Memory and inference
Memory and inference
Cognition
Cognitive system
Mental representation system
Sensory system
Information acquisition
Information acquisition
Information acquisition system
Information acquisition
Sensation
Each system can operate in isolation but is
usually strongly under the influence of other
systems
7
Outline

• Defining addiction and motivation
• Developing a theory of motivation
• Applying the theory to addiction to cigarettes

8
A starting point for understanding behaviour

• 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

9
Example

• Faced with what appears to be a 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

10
A possible structure for the motivational system

• 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)

11
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
12
Oughts

• We use the term ought or should to refer to
  actions that we do not want to do or feel a need
  to do but which we evaluate positively
• According to PRIME Theory, oughts will not lead
  to behaviour unless they can interact with
  identity (see later) to generate wants or needs

13
Implications

• All goal directed behaviour is channelled through
  motives (wants and needs) operating in the
  moment
• Motives are not the same as intentions or
  cognitions
• Evaluations and intentions will not influence
  behaviour unless they generate motives at the
  relevant time
• Therefore measuring motives offers the best
  prediction of goal directed behaviour and the
  best starting point for understanding it
• Shift in focus from beliefs and intentions at the
  time of measurement to predicting wants and needs
  in the future

14
Dispositions and how they change

• Dispositions refer to characteristics of the
  system that govern its operation
• Dispositions vary in stability and context
  sensitivity
• Dispositions change through
• maturation
• learning
• habituation and sensitisation
• associative learning
• explicit memory
• analysis
• re-formulation
• The process of change is chaotic (involving
  semi-stable states with pseudo-random switching
  during periods of instability) and dialectic
  (involving mutually interacting elements)

15
Implications

• Behaviour change need not proceed in a linear
  fashion through stages change from one major
  disposition to another can
• occur in a single complete transformation
• happen without being intended
• involve periods of instability of varying
  duration
• occur in response to apparently insignificant
  triggers

16
The role of identity

• Identity refers to our disposition to form mental
  representations of ourselves and the feelings
  attached to these
• It is a potentially important source of motives
• It is the ultimate source of self-regulation
• It is a major source of stability of behaviour
• Major elements are
• Labels (e.g. non-smoker)
• Attributes (e.g. health-conscious)
• Rules (e.g. I do not smoke)

17
Deliberate cessation of behaviour patterns

• 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 which adds
  to those that led to the rule

18
Self-control

• Self-control refers to the self-conscious
  application of a plan/rule in the face of
  competing wants, need or impulses
• This process is effortful and require and use
  mental energy to the extent that it involves
  conflict with other wants and needs
• Deep identity change involving changes to
  labels, attributes and development of rules with
  clear boundaries opposes formation of conflicting
  wants and needs and reduces conflict

19
Implications

• A strong, coherent, deeply entrenched identity
  that places clear boundaries around a category of
  behaviour and which anticipates potential
  challenges will provide strong stability to that
  behaviour and yield a powerful predictive measure
• Fostering such an identity around a new behaviour
  pattern is a potentially important target for
  behaviour change interventions

20
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 in the form of rules have a vital role to
  play in organising our behaviour and protecting
  our longer term interests in the face of
  immediate demands
• Implementing them in the face of conflicting
  wants, needs and urges can be effortful and use
  up mental resources
• But deep identity change and rules with clear
  boundaries reduce conflict and effort required

21
Outline

• Defining addiction and motivation
• Developing a theory of motivation
• Applying the theory to addiction to cigarettes

22
Understanding why 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 plan to go for a cigarette during coffee
  breaks
• These motivations are stronger than any competing
  motivations including a plan not to smoke

23
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

24
Nicotine reward

• When nicotine is absorbed it attaches to
  nicotinic acetylcholine receptors in the Ventral
  Tegmental Area (VTA) of the mid brain
• This stimulates firing of neurons that project
  forward to the Nucleus Accumbens (NAcc)
• This causes dopamine release in the NAcc
• This results in
• an impulse (urge) to smoke in situations that
  have been associated with smoking
• a mildly pleasant sensation
• amplification of pleasures arising from other
  rewards present at the time
• a belief that smoking is enjoyable and adds
  pleasure to life

25
Mesolimbic dopamine pathway
Nucleus accumbens
Ventral tegmental area
26
Drug actions on the mesolimbic pathway
27
Nicotine hunger

• After repeated ingestion of nicotine, the
  motivational pathways are altered to create a
  drive, somewhat similar to hunger, except that
  it is for cigarettes
• The drive increases in the minutes to hours since
  the last cigarette and is influenced by triggers,
  reminders, stress and distractions
• The drive is experienced as a need to smoke
• It usually reduces over weeks of not smoking but
  can re-emerge unexpectedly
• Relief from this need can be pleasurable and
  memory of the pleasure makes smokers feeling that
  they want to smoke the expect to enjoy it

28
Nicotine withdrawal symptoms

• After repeated nicotine exposure, abstinence
  results in unpleasant withdrawal symptoms
  including depression
• Adverse mood therefore comes to generate a need
  to smoke and a belief that smoking can help with
  stress and concentration

29
The process of smoking cessation

• The process of smoking cessation involves a
  number of events
• the quit attempt
• initiation of a rule that smoking is not
  permitted
• arises at a moment when the desire to stop now is
  greater than the desire to carry on
• lapse
• smoking a cigarette but keeping or suspending the
  no-smoking rule
• arises when the desire to smoke is greater than
  the desire not to
• relapse
• abandoning the no smoking rule
• arises when the desire to abandon the no-smoking
  rule is greater than the desire to keep it

30
Wants and oughts to stop smoking

• 3173 adult cigarette smokers in the Smoking
  Toolkit Study
• Allowed to endorse either or both of
• I want to stop smoking
• I ought to stop smoking
• Reports of want to stop are lower than seen
  when asked on its own
• In multiple logistic regression, only want is
  associated with quit attempts

31
Why smoking cessation is difficult

• 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

32
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
33
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

34
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

35
Implications a reminder

• All goal directed behaviour is channelled through
  motives (wants and needs) operating in the
  moment
• Motives are not the same as intentions or
  cognitions
• Evaluations and intentions will not influence
  behaviour unless they generate motives at the
  relevant time
• Therefore measuring motives offers the best
  prediction of goal directed behaviour and the
  best starting point for understanding it
• Shift in focus from beliefs and intentions at the
  time of measurement to predicting wants and needs
  in the future

36
A simplification of PRIME Theory

• Most of our actions involve following what we
  most want or need at that moment
• Wanting and needing involve forming an image of a
  possible future and feelings associated with this
• Want feeling of anticipated pleasure or
  satisfaction
• Need feeling of anticipated relief
• We follow wants and needs when we can imagine how
  to attain them or can do it without conscious
  thought to generate impulses
• Oughts (wants and needs based purely on plans)
  carry little motivational impact

37
Predicting smoking cessation

• Medium term prediction of attempts to stop
  smoking
• Thinking back over the past few weeks how much of
  the time have you felt you wanted to stop
  smoking?
• How strong has that desire been?
• Prediction of early relapse
• How much of the time have you felt urges to
  smoke?
• How strong have those urges been?
• Prediction of late relapse in short-term
  successes
• Do you now think of yourself as a non-smoker for
  whom smoking is not something you would even
  contemplate doing?

38
Predicting successful interventions

• Generating quit attempts in unselected smokers
• focus on triggering action rather than changing
  beliefs
• promote use of effective aids to cessation to all
  smokers without asking whether they are
  interested in stopping first
• time interventions to coincide with each other or
  other times of heightened motivation to change
• Aiding quit attempts
• focus on developing and fostering a new identity
• abrupt not gradual change
• clear boundaries (not a puff)
• re-evaluate place of smoking in relation to other
  core identities

39
Review

• Motivation involves multiple levels from impulses
  to plans higher levels must work through lower
  levels
• Wants and needs in the moment are the key to
  goal-directed behaviour
• Plans/rules provide structure and stability but
  must create wants and needs at the relevant time
• Self-control is fundamental to deliberate
  behaviour change and stems from self-conscious
  plans interacting with identity to generate wants
  and needs
• Self-control is effortful but less so when it
  involves deep identity change and rules with
  clear boundaries