Reducing AddictiveBehaviour• Why is it important that we find effectiveways of reducing addictive behaviour?• What are the consequences of reducingaddictive behaviour?• What methods have we got to preventaddictive behaviour?• Which of these methods do you think are mosteffective?
What’s on the Specification?• Models of Prevention:– Theory of planned behaviour• Types of Intervention:– Biological intervention– Psychological intervention– Public health intervention
Reducing AddictiveBehaviour• Once ‘hooked’ to an addictive behaviour it isvery difficult to stop.• Better to stop people from engaging in theseaddictive behaviours before addiction begins.EducationTo introduce socialchange• Increase cost• Control advertisingA01
The Theory of Planned Behaviour(TPB) Ajzen (1988)The TPB attempts to explain some ofthe factors influencing behaviour thatthe TRA model cannot explain. Theextended theory contained an additionalcomponent of ‘perceived behaviouralcontrol’ which is similar to the idea of‘self-efficacy’ Bandura, 1977A01
The strength ofthe belief aboutthe outcomes ofthe behaviourNormative beliefsabout the attitude ofimportant others.The motivation tocomply with theexpectations ofothersControl FactorsInternalExternalAttitudes towards thebehaviourSubjectivenormsBehaviouralintentionBehaviourPerceivedbehavioural controlA01The Theory of Planned Behaviour(TPB) Ajzen (1988)
Attitude – positive/negativeevaluation of the behaviourSubjective norm – Perception ofnorms/pressures to performbehaviour (including motivation tocomply)Perceived behavioural control –belief that they can carry out thebehaviour based on internal &external control factorsBehaviouralintentionActualBehaviourOn the TPB sheets infront of you, in pairs thinkof as many attitudes,subjective norms andbehavioural controls asyou can think of relatingto smokingA01The Theory of Planned Behaviour(TPB) Ajzen (1988)
Attitude towards thebehaviour- Smoking is bad for yourhealth- Smoking costs lots ofmoney- It can be difficult to stopSubjective norms- I would be the onlysmoker in my peer group- My friends do like smokingPerceived behaviouralcontrol- I’m not sure I could stopsmoking when I wanted toBehaviouralintentionActualBehaviourI.e., stop/not startsmokingA01The Theory of Planned Behaviour(TPB) Ajzen (1988)
Using TPB as prevention• Changing the attitude• ONDCP attempt to educate teenagers about the real effects of marijuanause (e.g. inconsistent with autonomy and achievement) to alter theirattitude towards the behaviourAttitude- Can be positive ornegative• Changing the subjective norm• Anti-drug campaigners seek to give adolescents actual data about thepercentage of people engaging in risky behaviour in an attempt torationalise their subjective normsSubjective norm- Perception ofsocial norms andpressures fromothers• Changing the perceived behavioural control• The 3 elements determine intention but perceived behavioural control wasthe most important• Therefore prevention programmes should focus on will-power required togive up and alert addicts that effort is required to modify their behaviourPerceivedbehaviouralcontrol- The extent towhich we believe wecan exert controlapplication
TPB as prevention A02Oh and Hsu (2001) Used aquestionnaire to assess gamblers’previous gambling behaviour, theirsocial norms, attitudes, perceivedbehavioural control (like perceivedgambling skills and levels of self-control) along with behaviouralintentions.A positive correlation was foundbetween their attitudes andbehavioural intentions and actualbehaviour, supporting the model.Too rational? The TPB has beencriticised for being too rational andfailing to take into account emotions,compulsions and other irrationaldeterminants of human behaviour.McMillan et al (2005)Used TPB toinvestigate factors underlyingsmoking intentions and latersmoking behaviour in schoolchildren. The theory produced goodpredictions of intentions, attitude,subjective norms and perceivedbehavioural control, thoughintentions did not fully predict thesubjective-norm behaviourrelationship, lending a degree ofsupport to the model.
TPB as prevention A02But why don’t people just stop/not start the behaviour?TPB may be reliant on invalid evidence as research tends to rely onself-reports, which may be subject to social desirability (e.g., addictsplaying down their degree of dependency) or because addicts may notbe aware of the true extent of their dependency. Similarly individualwho haven’t yet engaged in certain behaviours might underplay/notrealise 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 ideathat the individuals appraisal of behaviours is rational and wellconsidered, which isn’t always the case
Types of Intervention• Biological Interventions• Psychological Interventions –Behavioural (see extension forCognitive)• Public Health InterventionsA01
InterventionsThere are many different reasons for developing addictivebehaviours and it is likely that people will not respond in the same wayto treatment programmes.Therefore the most successful interventions are multicomponentprogrammes that can be tailored to meet the needs of the individual.It is also important to recognise that some therapies are specific tothe particular addictive substance (e.g., alcohol or nicotine) oraddictive behaviour (e.g., gambling).Any successful intervention also depends on the motivation of theindividual to change their behaviour. This can be a major stumblingblock with people with addictions because often they refuse to admitthey have a problem.A01
Stages of Change ModelIf and when people with addictive problems (e.g., smoking, alcohol, drug-taking, gambling, etc) come forward to seek help, the intervention offeredwill depend on the stage they have reached in their addictive cycle.Prochaska and DiClemente (1983) put forward their stages-of-change modelto describe the processes involved in overcoming addiction:1 Pre-contemplation2 Contemplation3 Preparation4 Action5 MaintenanceAccording to this model, progress across the stages is not straightforwardand individuals can switch backwards and forwards. They call this the‘revolving door phenomenon’. DiClemente et al (1991) found that people in thepreparation stage where much more likely to have made an attempt to giveup smoking at one- and six- month follow-up than people in the contemplationstage.
Biological Interventions• Biological therapies are based on the idea of addiction as a diseaseand usually involve the use of medication.• Normally aim for complete abstinence.• If an individual abstains from a previously addictive behaviour, it isalmost inevitable that they will develop withdrawal symptoms.• Important part of any treatment programme to manage thesewithdrawal symptoms when they occur.• They can be very severe (e.g., seizures and delirium), particularly inthe case of alcohol and illegal drugs, and often require the individualto stay in hospital to ensure adequate supervision.• Biological interventions have been widely used to help people give upsmoking.A01
Biological InterventionsThree classes of medications have been approved for smokingcessation:1. Nicotine replacement (patch, gum, spray, inhaler and lozenge)2. Bupropion3. Varenicline (the most recent and approved)1. Nicotine replacement therapy (NRT)• Nicotine medication such as nicotine gum, patches and nasal sprays, mimic or replacethe effects of nicotine derived from tobacco. They help people to stop smoking inseveral ways:• Even in relatively low doses, they help to relieve withdrawal symptoms when a personstops using tobacco.• Some of these products are self-administered and provide positive reinforcement,particularly because of their arousal and stress relieving effects. However, nicotinepatches deliver nicotine gradually and result in sustained nicotine levels throughoutthe day, thus not providing much positive reinforcement.• They seem to desensitise nicotine receptors in the brain. This means that if a personlapses and smokes a cigarette while on nicotine replacement therapy, the cigaretteswill appear less satisfying.A01
Biological Interventions2. BupropionThe anti depressant drug Bupropion has also been used as a treatment forsmoking. It works by increasing brain levels of dopamine and norepinephrine,simulating the effects of nicotine on these neurotransmitters. As one effectof Bupropion seems to be to block the nicotine receptor, so, as with nicotinereplacement therapies, it could reduce the positive reinforcement of acigarette. In the case of a lapse, it has been shown to have been reasonablysuccessful in treating cigarette smoking (Watts et al 2002).3. VareniclineVarenicline is a drug that causes dopamine release in the brain. Italso blocks the effects of any nicotine added to the system. Clinicaltrials have found that Varenicline is superior to Bupropion in helpingpeople to stop smoking. It has also been shown to reduce relapse insmokers who had been abstinent 12 weeks after initial therapy.A01
Biological InterventionsNicotine VaccinesThese are currently undergoing clinical trials.Acute immunisation is performed so as to developanti bodies to nicotine. The anti body binds to thenicotine and slows its entry to the brain,therefore reducing the reinforcing effects ofcigarette smoking. If it proves effective, thenicotine vaccine will be a logical approach topreventing relapse.A01
Biological Interventions - Effectiveness• Chance of relapse - The currently available nicotine replacement therapies deliver nicotineinto 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 willgive up the therapy and relapse.• Effective - Moor et al 2009 assessed the effectiveness of a range of nicotine replacementtherapies and found them to be an effective intervention therapy in achieving sustainedabstinence for smokers who cannot or will not attempt immediate abstinence.• Not effective - Varenicline used to treat smoking dependency, can result in depression andsuicide although withdrawal symptoms may contribute to this.There are some concerns involving the safety of using nicotine itself as a part of atherapeutic approach.• Nicotine increases heart rate, constricts coronary blood vessels and temporarily increasesblood pressure, as well as having a role in cancer, reproductive disorders and delayed woundhealing.• Nicotine can also have adverse effects on foetuses and there are concerns that it may be atumour promoter.However, if the alternative is smoking, then nicotine isundoubtedly less harmful.A02
Other Biological InterventionsDetoxification Programmes These involve gradual or instant abstentionand often use antagonistic drugs which block neurotransmitterreceptors so that synaptic transmission is prevented, thus reducingwithdrawal effects.Drug Maintenance TherapyThis involves substitute drugs (e.g. methadone for heroin addicts whichproduces less of a high and is taken orally). This therapy does notinvolve contextual cues, like needles and pipes (to try to break thelearnt ‘association’).IDEA’s• Reductionist• DeterministicA01
Other Biological InterventionsEffectiveness:Warren et al 2005 assessed the effectiveness of methadone as a treatmentfor heroin addiction among 900 prisoners. Inmates who received methadoneused heroin on average for 15.24 days a year compared to 99.6 days a yearfor inmates not receiving methadone; showing methadone treatment to beextremely effective.However, methadone has been associated with psychiatric disorders (e.g.depression). Trauer (2008) found that those on methadone maintenance are10 times more likely to have a psychiatric disorder than the generalpopulation.IDEA’s• Reductionist• DeterministicA02
Behavioural TherapyAversion therapyThis is a behaviourist treatment based on classical conditioning where a negativeeffect is paired with the addictive substance so that the two become associated.It has been used to treat alcohol addiction and smoking addiction. Earlyprogrammes which administered a mild electric shock every time the individualtook a sip of alcohol or a puff on a cigarette were not successful because theeffects did not last outside of the clinic setting (i.e., they did not successfullygeneralise outside of the controlled environment).Alcoholics are given the drug Antabuse (an emetic) which makes them sick every timethey 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)A01
Behavioural TherapyAversion therapyThis is a behaviourist treatment based on classical conditioning where a negativeeffect is paired with the addictive substance so that the two become associated.It has been used to treat alcohol addiction and smoking addiction. Earlyprogrammes which administered a mild electric shock every time the individualtook a sip of alcohol or a puff on a cigarette were not successful because theeffects did not last outside of the clinic setting (i.e., they did not successfullygeneralise outside of the controlled environment).Aversion therapy for smoking addiction:A form of aversion therapy called ‘rapid smoking’ has had some success forsmoking addiction.The individual is required to sit in a closed room and take puffs on a cigaretteevery six seconds, which is much faster than normal. This rapid inhalation leadsto feelings of nausea and makes the individual feel quite ill. The idea underpinningthis therapy is that the smoker will associate unpleasant feelings with smokingand so they will develop an aversion to cigarettes (Spiegler and Guevremont,2003).A01
Behavioural TherapyEffectiveness of aversion therapy:+VEO’Farrel et al (1985) found that aversion therapy using the drug Antabuse was successful in treatingmale alcoholics when combined with behavioural marital therapy, supporting the use of aversiontherapy for alcohol addiction.There is some evidence that that this can help some people to give up smoking, particularly when usedas 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 tacklingthe underlying cause of the addictive behaviour, therefore it is likely that if the cause stillremains, 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 bethere after the treatment).• Using Antabuse has not been shown to be effective in the long-term and the use of this treatmenthas been questioned on ethical grounds.A02
Behavioural TherapyIDEA’s• A highly distressing treatment – stories of peoplelying in hospital bed lying in vomit and urine• Can be highly dangerous – people have diedthrough choking on vomit• Used to be used on male homosexuals – againsttheir will – through a court order.A02
Behavioural TherapyOperant ConditioningThis is another behaviourist treatment, based on voluntary behaviours.Reinforcement (e.g., being allowed visits, access to the Internet etc) isexperienced each time an addict stays drug free for a target period.Token economies (based on operant conditioning) can be used in therapeuticcommunities, where non-addictive behaviour is rewarded with tokens that canbe exchanged for desirable goods.AO1EffectivenessHiggins et al (1994) found that 75% of cocaine addicts using operantconditioning in the form of token economies completed a drugrehabilitation course, compared to 40% using psychotherapy. Thisshows…AO2Behavioural treatments often have short-term, but not long-term success in addressingaddictions, possibly because they are addressing the effects of dependency rather than itscauses.
Public Health Interventions- Doctors’ adviceDoctors’ advice ~70% of smokers in the UK consult their GP each yearDoctors are seen by many people as authoritative and creditable sourcesof information about health issues and so they have a clear role to playin advising people about the dangers of excessive smoking and drinking.A study carried out across five London GP practices compared results where patients were givenvarying 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% hadgiven up smoking at 12 months.Advised by the doctor to give up smoking, filled in questionnaire about their smokinghabits 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 andgiven follow-up: 5.1% had given up at 12 months.A01
AO2 commentary: Could doctors’ advice really be effective in helping to solvethe problem of smoking addiction?• These look like small changes, but if all GPs advised their smoker patients togive up and provided them with some tips about how to do this, it wouldproduce 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 adviceand information at an early stage when safer drinking levels rather than completeabstention might be appropriate.AO2 ~ Effectiveness: Such brief interventions can be successful in people withmild alcohol problems, but not for those who have become alcohol dependent.(Room et al, 2005)Public Health Interventions- Doctors’ adviceA02
Public Health InterventionsWorkplace intervention: Over recent years, more and more businessesand 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 smokein public buildings in the UK. The primary purpose of this legislationswas to protect workers (and the public) from the harmful effects ofpassive smoking.A01
Public Health InterventionsLegislation: One way of discouraging smoking or excessive alcohol intake is viagovernment 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 funthings to do. Social learning theory would suggest that such advertising causes us to associatethese kinds of characteristics with smoking and drinking. If this is the case then a ban on suchadvertising should remove this source of learning.• In the UK, cigarette advertising was banned in 2003 and cannot now be shown in any publicform.• Alcohol advertising is still legal in the UK, but alcohol providers argue that advertisingsimply encourages existing drinkers to change brands rather than encouraging increasedoverall consumption. However, In the UK, annual expenditure on alcohol advertising rosefrom £150 million to £250 million between 1989 and 2000.A01
Public Health InterventionsEffectiveness…However, a health campaign was put in place alongside this legislation andresearch has shown that with the help of this campaign (involving the NHSStop Smoking Service) approximately one quarter of a million people quitsmoking between April and December 2007.It was found that this new law provided a supportive environment forsmokers to quit and the heath campaign helped to raise the awareness ofassociated health issues!!A02
Public Health InterventionsContinued…Increasing the cost - one possible strategy is to substantially raisethe price of cigarettes and alcoholic drinks. There does seem to be arelationship between the cost of cigarettes and alcohol and the amountthat is bought. In cognitive terms, this could be a powerful factor whenpeople are weighing up the perceived costs of their behaviour against theperceived benefitsControl of sales - Another preventative measure could be to controlthe sale of alcohol, cigarettes, lottery cards, etc. There are alreadyrestrictions in place in terms of age, but some people argue that alcohol,for example, is too widely available and easy to buy. In fact, legislationhas been relaxed so that supermarkets can now sell alcoholic drinksaround the clock seven days a week.Reduce harmful components - A proposal in the USA supported bythe American Medical Association (AMA) suggested a gradual reduction inthe nicotine content of cigarettes over a period of years so that smokerswould be gradually weaned from nicotine addiction, and find it easier togive up cigarette smoking.
Public Health InterventionsContinued…Ban on smoking in public -Public smoking has gradually becomeless acceptable in the UK andlegislation introduced in July 2007means that it is now against the lawto smoke in any enclosed publicplaces in England. This followedsimilar bans in other countries.- Such a ban should reduce thelikelihood of currently commoncues to smoking but people mightsimply compensate by drinking andsmoking more at home- There is also the danger thatsuch a ban may encourage a senseof group solidarity or a feeling ofshared ‘wickedness’ making thehabit seem more attractive.Complete ban? -It is already illegal to takecertain types of drugs such ascannabis, heroin and cocaine. Thelegal ban on the recreational useof such substances has obviouslynot eradicated the problem ofdrug addiction. In fact, somepeople have lobbied for thelegislation of these drugs as away of making them morecontrollable. A complete ban oncigarette smoking and alcoholconsumption seems to be highlyunlikely for political reasons.