2. Reducing Addictive
Behaviour
• Why is it important that we find effective
ways of reducing addictive behaviour?
• What are the consequences of reducing
addictive behaviour?
• What methods have we got to prevent
addictive behaviour?
• Which of these methods do you think are most
effective?
3. What’s on the Specification?
• Models of Prevention:
– Theory of planned behaviour
• Types of Intervention:
– Biological intervention
– Psychological intervention
– Public health intervention
4. Reducing Addictive
Behaviour
• Once ‘hooked’ to an addictive behaviour it is
very difficult to stop.
• Better to stop people from engaging in these
addictive behaviours before addiction begins.
Education
To introduce social
change
• Increase cost
• Control advertising
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5. The Theory of Planned Behaviour
(TPB) Ajzen (1988)
The TPB attempts to explain some of
the factors influencing behaviour that
the TRA model cannot explain. The
extended theory contained an additional
component of ‘perceived behavioural
control’ which is similar to the idea of
‘self-efficacy’ Bandura, 1977
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6. The strength of
the belief about
the outcomes of
the behaviour
Normative beliefs
about the attitude of
important others.
The motivation to
comply with the
expectations of
others
Control Factors
Internal
External
Attitudes towards the
behaviour
Subjective
norms
Behavioural
intention
Behaviour
Perceived
behavioural control
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The Theory of Planned Behaviour
(TPB) Ajzen (1988)
7. Attitude – positive/negative
evaluation of the behaviour
Subjective norm – Perception of
norms/pressures to perform
behaviour (including motivation to
comply)
Perceived behavioural control –
belief that they can carry out the
behaviour based on internal &
external control factors
Behavioural
intention
Actual
Behaviour
On the TPB sheets in
front of you, in pairs think
of as many attitudes,
subjective norms and
behavioural controls as
you can think of relating
to smoking
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The Theory of Planned Behaviour
(TPB) Ajzen (1988)
8. Attitude towards the
behaviour
- Smoking is bad for your
health
- Smoking costs lots of
money
- It can be difficult to stop
Subjective norms
- I would be the only
smoker in my peer group
- My friends do like smoking
Perceived behavioural
control
- I’m not sure I could stop
smoking when I wanted to
Behavioural
intention
Actual
Behaviour
I.e., stop/
not start
smoking
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The Theory of Planned Behaviour
(TPB) Ajzen (1988)
9. Using TPB as prevention
• Changing the attitude
• ONDCP attempt to educate teenagers about the real effects of marijuana
use (e.g. inconsistent with autonomy and achievement) to alter their
attitude towards the behaviour
Attitude
- Can be positive or
negative
• Changing the subjective norm
• Anti-drug campaigners seek to give adolescents actual data about the
percentage of people engaging in risky behaviour in an attempt to
rationalise their subjective norms
Subjective norm
- Perception of
social norms and
pressures from
others
• Changing the perceived behavioural control
• The 3 elements determine intention but perceived behavioural control was
the most important
• Therefore prevention programmes should focus on will-power required to
give up and alert addicts that effort is required to modify their behaviour
Perceived
behavioural
control
- The extent to
which we believe we
can exert control
application
10. TPB as prevention A02
Oh and Hsu (2001) Used a
questionnaire to assess gamblers’
previous gambling behaviour, their
social norms, attitudes, perceived
behavioural control (like perceived
gambling skills and levels of self-
control) along with behavioural
intentions.
A positive correlation was found
between their attitudes and
behavioural intentions and actual
behaviour, supporting the model.
Too rational? The TPB has been
criticised for being too rational and
failing to take into account emotions,
compulsions and other irrational
determinants of human behaviour.
McMillan et al (2005)Used TPB to
investigate factors underlying
smoking intentions and later
smoking behaviour in school
children. The theory produced good
predictions of intentions, attitude,
subjective norms and perceived
behavioural control, though
intentions did not fully predict the
subjective-norm behaviour
relationship, lending a degree of
support to the model.
11. TPB as prevention A02
But why don’t people just stop/not start the behaviour?
TPB may be reliant on invalid evidence as research tends to rely on
self-reports, which may be subject to social desirability (e.g., addicts
playing down their degree of dependency) or because addicts may not
be aware of the true extent of their dependency. Similarly individual
who haven’t yet engaged in certain behaviours might underplay/not
realise the extent to which other factors influence their decision
(e.g. the desire to fit into a specific group who smokes).
This means that the theory of planned behaviour works on the idea
that the individuals appraisal of behaviours is rational and well
considered, which isn’t always the case
13. Types of Intervention
• Biological Interventions
• Psychological Interventions –
Behavioural (see extension for
Cognitive)
• Public Health Interventions
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14. Interventions
There are many different reasons for developing addictive
behaviours and it is likely that people will not respond in the same way
to treatment programmes.
Therefore the most successful interventions are multicomponent
programmes that can be tailored to meet the needs of the individual.
It is also important to recognise that some therapies are specific to
the particular addictive substance (e.g., alcohol or nicotine) or
addictive behaviour (e.g., gambling).
Any successful intervention also depends on the motivation of the
individual to change their behaviour. This can be a major stumbling
block with people with addictions because often they refuse to admit
they have a problem.
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15. Stages of Change Model
If and when people with addictive problems (e.g., smoking, alcohol, drug-
taking, gambling, etc) come forward to seek help, the intervention offered
will depend on the stage they have reached in their addictive cycle.
Prochaska and DiClemente (1983) put forward their stages-of-change model
to describe the processes involved in overcoming addiction:
1 Pre-contemplation
2 Contemplation
3 Preparation
4 Action
5 Maintenance
According to this model, progress across the stages is not straightforward
and individuals can switch backwards and forwards. They call this the
‘revolving door phenomenon’. DiClemente et al (1991) found that people in the
preparation stage where much more likely to have made an attempt to give
up smoking at one- and six- month follow-up than people in the contemplation
stage.
16. Biological Interventions
• Biological therapies are based on the idea of addiction as a disease
and usually involve the use of medication.
• Normally aim for complete abstinence.
• If an individual abstains from a previously addictive behaviour, it is
almost inevitable that they will develop withdrawal symptoms.
• Important part of any treatment programme to manage these
withdrawal symptoms when they occur.
• They can be very severe (e.g., seizures and delirium), particularly in
the case of alcohol and illegal drugs, and often require the individual
to stay in hospital to ensure adequate supervision.
• Biological interventions have been widely used to help people give up
smoking.
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17. Biological Interventions
Three classes of medications have been approved for smoking
cessation:
1. Nicotine replacement (patch, gum, spray, inhaler and lozenge)
2. Bupropion
3. Varenicline (the most recent and approved)
1. Nicotine replacement therapy (NRT)
• Nicotine medication such as nicotine gum, patches and nasal sprays, mimic or replace
the effects of nicotine derived from tobacco. They help people to stop smoking in
several ways:
• Even in relatively low doses, they help to relieve withdrawal symptoms when a person
stops using tobacco.
• Some of these products are self-administered and provide positive reinforcement,
particularly because of their arousal and stress relieving effects. However, nicotine
patches deliver nicotine gradually and result in sustained nicotine levels throughout
the day, thus not providing much positive reinforcement.
• They seem to desensitise nicotine receptors in the brain. This means that if a person
lapses and smokes a cigarette while on nicotine replacement therapy, the cigarettes
will appear less satisfying.
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18. Biological Interventions
2. Bupropion
The anti depressant drug Bupropion has also been used as a treatment for
smoking. It works by increasing brain levels of dopamine and norepinephrine,
simulating the effects of nicotine on these neurotransmitters. As one effect
of Bupropion seems to be to block the nicotine receptor, so, as with nicotine
replacement therapies, it could reduce the positive reinforcement of a
cigarette. In the case of a lapse, it has been shown to have been reasonably
successful in treating cigarette smoking (Watts et al 2002).
3. Varenicline
Varenicline is a drug that causes dopamine release in the brain. It
also blocks the effects of any nicotine added to the system. Clinical
trials have found that Varenicline is superior to Bupropion in helping
people to stop smoking. It has also been shown to reduce relapse in
smokers who had been abstinent 12 weeks after initial therapy.
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19. Biological Interventions
Nicotine Vaccines
These are currently undergoing clinical trials.
Acute immunisation is performed so as to develop
anti bodies to nicotine. The anti body binds to the
nicotine and slows its entry to the brain,
therefore reducing the reinforcing effects of
cigarette smoking. If it proves effective, the
nicotine vaccine will be a logical approach to
preventing relapse.
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20. Biological Interventions - Effectiveness
• Chance of relapse - The currently available nicotine replacement therapies deliver nicotine
into the bloodstream much more slowly than cigarette smoking does. So for most smokers,
nicotine medications are not seen as being as satisfying as smoking a cigarette and some will
give up the therapy and relapse.
• Effective - Moor et al 2009 assessed the effectiveness of a range of nicotine replacement
therapies and found them to be an effective intervention therapy in achieving sustained
abstinence for smokers who cannot or will not attempt immediate abstinence.
• Not effective - Varenicline used to treat smoking dependency, can result in depression and
suicide although withdrawal symptoms may contribute to this.
There are some concerns involving the safety of using nicotine itself as a part of a
therapeutic approach.
• Nicotine increases heart rate, constricts coronary blood vessels and temporarily increases
blood pressure, as well as having a role in cancer, reproductive disorders and delayed wound
healing.
• Nicotine can also have adverse effects on foetuses and there are concerns that it may be a
tumour promoter.
However, if the alternative is smoking, then nicotine is
undoubtedly less harmful.
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21. Other Biological Interventions
Detoxification Programmes These involve gradual or instant abstention
and often use antagonistic drugs which block neurotransmitter
receptors so that synaptic transmission is prevented, thus reducing
withdrawal effects.
Drug Maintenance Therapy
This involves substitute drugs (e.g. methadone for heroin addicts which
produces less of a high and is taken orally). This therapy does not
involve contextual cues, like needles and pipes (to try to break the
learnt ‘association’).
IDEA’s
• Reductionist
• Deterministic
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22. Other Biological Interventions
Effectiveness:
Warren et al 2005 assessed the effectiveness of methadone as a treatment
for heroin addiction among 900 prisoners. Inmates who received methadone
used heroin on average for 15.24 days a year compared to 99.6 days a year
for inmates not receiving methadone; showing methadone treatment to be
extremely effective.
However, methadone has been associated with psychiatric disorders (e.g.
depression). Trauer (2008) found that those on methadone maintenance are
10 times more likely to have a psychiatric disorder than the general
population.
IDEA’s
• Reductionist
• Deterministic
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23. Behavioural Therapy
Aversion therapy
This is a behaviourist treatment based on classical conditioning where a negative
effect is paired with the addictive substance so that the two become associated.
It has been used to treat alcohol addiction and smoking addiction. Early
programmes which administered a mild electric shock every time the individual
took a sip of alcohol or a puff on a cigarette were not successful because the
effects did not last outside of the clinic setting (i.e., they did not successfully
generalise outside of the controlled environment).
Alcoholics are given the drug Antabuse (an emetic) which makes them sick every time
they drink alcohol. This establishes a link between alcohol in drinks and vomiting.
UCS UCR
(Antabuse) (Vomit)
UCS NS UCR
(Antabuse) (Alcohol) (Vomit)
CS CR
(Alcohol) (Vomit)
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24. Behavioural Therapy
Aversion therapy
This is a behaviourist treatment based on classical conditioning where a negative
effect is paired with the addictive substance so that the two become associated.
It has been used to treat alcohol addiction and smoking addiction. Early
programmes which administered a mild electric shock every time the individual
took a sip of alcohol or a puff on a cigarette were not successful because the
effects did not last outside of the clinic setting (i.e., they did not successfully
generalise outside of the controlled environment).
Aversion therapy for smoking addiction:
A form of aversion therapy called ‘rapid smoking’ has had some success for
smoking addiction.
The individual is required to sit in a closed room and take puffs on a cigarette
every six seconds, which is much faster than normal. This rapid inhalation leads
to feelings of nausea and makes the individual feel quite ill. The idea underpinning
this therapy is that the smoker will associate unpleasant feelings with smoking
and so they will develop an aversion to cigarettes (Spiegler and Guevremont,
2003).
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25. Behavioural Therapy
Effectiveness of aversion therapy:
+VE
O’Farrel et al (1985) found that aversion therapy using the drug Antabuse was successful in treating
male alcoholics when combined with behavioural marital therapy, supporting the use of aversion
therapy for alcohol addiction.
There is some evidence that that this can help some people to give up smoking, particularly when used
as part of a multicomponent programme.
However......
-VE
• The results have not been consistent across studies.
• There is a slight risk for people who have cardiopulmonary disorders.
• Another problem is that this focuses on the act of smoking (the behaviour) rather than tackling
the underlying cause of the addictive behaviour, therefore it is likely that if the cause still
remains, the behaviour will probably return.
Alcohol addiction:
• The treatment requires the person to take the drug in the first place and they may not comply.
• It ignores the reasons that led to the alcoholism in the first place (which will probably still be
there after the treatment).
• Using Antabuse has not been shown to be effective in the long-term and the use of this treatment
has been questioned on ethical grounds.
A02
26. Behavioural Therapy
IDEA’s
• A highly distressing treatment – stories of people
lying in hospital bed lying in vomit and urine
• Can be highly dangerous – people have died
through choking on vomit
• Used to be used on male homosexuals – against
their will – through a court order.
A02
27. Behavioural Therapy
Operant Conditioning
This is another behaviourist treatment, based on voluntary behaviours.
Reinforcement (e.g., being allowed visits, access to the Internet etc) is
experienced each time an addict stays drug free for a target period.
Token economies (based on operant conditioning) can be used in therapeutic
communities, where non-addictive behaviour is rewarded with tokens that can
be exchanged for desirable goods.
AO1
Effectiveness
Higgins et al (1994) found that 75% of cocaine addicts using operant
conditioning in the form of token economies completed a drug
rehabilitation course, compared to 40% using psychotherapy. This
shows…
AO2
Behavioural treatments often have short-term, but not long-term success in addressing
addictions, possibly because they are addressing the effects of dependency rather than its
causes.
28. Public Health Interventions
- Doctors’ advice
Doctors’ advice ~
70% of smokers in the UK consult their GP each year
Doctors are seen by many people as authoritative and creditable sources
of information about health issues and so they have a clear role to play
in advising people about the dangers of excessive smoking and drinking.
A study carried out across five London GP practices compared results where patients were given
varying degrees of assistance:
Given follow-up only: 0.3% had given up smoking at 12 months.
Filled in questionnaire about their smoking habits and then given follow-up: 1.6% had
given up smoking at 12 months.
Advised by the doctor to give up smoking, filled in questionnaire about their smoking
habits and then given follow-up: 3.3% had given up at 12 months.
Advised by the doctor to give up smoking, given a leaflet with tips for giving up and
given follow-up: 5.1% had given up at 12 months.
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29. AO2 commentary: Could doctors’ advice really be effective in helping to solve
the problem of smoking addiction?
• These look like small changes, but if all GPs advised their smoker patients to
give up and provided them with some tips about how to do this, it would
produce half a million ex-smokers within a year in the UK (Ogden, 2007)
Doctors are also well placed to provide early treatment for alcohol problems.
They are likely to know the patient and their family quite well and can give advice
and information at an early stage when safer drinking levels rather than complete
abstention might be appropriate.
AO2 ~ Effectiveness: Such brief interventions can be successful in people with
mild alcohol problems, but not for those who have become alcohol dependent.
(Room et al, 2005)
Public Health Interventions
- Doctors’ advice
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30. Public Health Interventions
Workplace intervention: Over recent years, more and more businesses
and other workplaces have adopted strategies for discouraging smoking.
These attempts have now been enforced by government legislation.
In July 2007, legislation came into force which meant it illegal to smoke
in public buildings in the UK. The primary purpose of this legislations
was to protect workers (and the public) from the harmful effects of
passive smoking.
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31. Public Health Interventions
Legislation: One way of discouraging smoking or excessive alcohol intake is via
government legislation or guidelines. This can take various forms:
• Restrictions or a ban on advertising.
• Increasing the cost.
• Controls on sales.
• Reducing the harmful components in cigarettes or drinks.
1. Restrictions or a ban on advertising.
Advertising aims to promote the idea that smoking and drinking are sophisticated and/or fun
things to do. Social learning theory would suggest that such advertising causes us to associate
these kinds of characteristics with smoking and drinking. If this is the case then a ban on such
advertising should remove this source of learning.
• In the UK, cigarette advertising was banned in 2003 and cannot now be shown in any public
form.
• Alcohol advertising is still legal in the UK, but alcohol providers argue that advertising
simply encourages existing drinkers to change brands rather than encouraging increased
overall consumption. However, In the UK, annual expenditure on alcohol advertising rose
from £150 million to £250 million between 1989 and 2000.
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32. Public Health Interventions
Effectiveness…
However, a health campaign was put in place alongside this legislation and
research has shown that with the help of this campaign (involving the NHS
Stop Smoking Service) approximately one quarter of a million people quit
smoking between April and December 2007.
It was found that this new law provided a supportive environment for
smokers to quit and the heath campaign helped to raise the awareness of
associated health issues!!
A02
33. Public Health Interventions
Continued…
Increasing the cost - one possible strategy is to substantially raise
the price of cigarettes and alcoholic drinks. There does seem to be a
relationship between the cost of cigarettes and alcohol and the amount
that is bought. In cognitive terms, this could be a powerful factor when
people are weighing up the perceived costs of their behaviour against the
perceived benefits
Control of sales - Another preventative measure could be to control
the sale of alcohol, cigarettes, lottery cards, etc. There are already
restrictions in place in terms of age, but some people argue that alcohol,
for example, is too widely available and easy to buy. In fact, legislation
has been relaxed so that supermarkets can now sell alcoholic drinks
around the clock seven days a week.
Reduce harmful components - A proposal in the USA supported by
the American Medical Association (AMA) suggested a gradual reduction in
the nicotine content of cigarettes over a period of years so that smokers
would be gradually weaned from nicotine addiction, and find it easier to
give up cigarette smoking.
34. Public Health Interventions
Continued…
Ban on smoking in public -
Public smoking has gradually become
less acceptable in the UK and
legislation introduced in July 2007
means that it is now against the law
to smoke in any enclosed public
places in England. This followed
similar bans in other countries.
- Such a ban should reduce the
likelihood of currently common
cues to smoking but people might
simply compensate by drinking and
smoking more at home
- There is also the danger that
such a ban may encourage a sense
of group solidarity or a feeling of
shared ‘wickedness’ making the
habit seem more attractive.
Complete ban? -
It is already illegal to take
certain types of drugs such as
cannabis, heroin and cocaine. The
legal ban on the recreational use
of such substances has obviously
not eradicated the problem of
drug addiction. In fact, some
people have lobbied for the
legislation of these drugs as a
way of making them more
controllable. A complete ban on
cigarette smoking and alcohol
consumption seems to be highly
unlikely for political reasons.
