No butts - Psychology can help you quit
Scotland did it last year, Wales and Northern Ireland joined them in April, now this month it’s England’s turn to follow suit by banning smoking from public places. As the fug lifts from thousands of bars and pubs across the land, the change in law poses several questions for psychology. How can psychology help people quit? What psychological effects does quitting have? And how will the ban change the way people view smoking?
Despite the known health risks of smoking, approximately 12 million adults smoke in the UK, and smoking remains the main cause of preventable and premature death in England, with 86,000 smoking-related deaths recorded between 1998 and 2002. Help to give up smoking has been available on the NHS since April 1999 and generally comes in the form of nicotine replacement therapy plus psychological support. Just how long that psychological support lasts, and who it is delivered by, depends on where you live.
‘We know that multi-session behavioural support delivered by people who are specifically trained in smoking cessation support, helps people to quit more successfully than if they relied on self-help,’ says Robert West, professor of health psychology, and Director of Tobacco Studies at the Cancer Research UK Health Behaviour Unit, London. ‘What we don’t know is whether one theory-driven approach – like CBT or motivational interviewing – works better than any others. Nor do we have any reliable evidence to indicate one particular orientation is better or worse than a pragmatic approach, of the kind that you or I could dream up, in which you just provide some empathic support, tell people what to expect, and teach them some coping skills.’
So we might not have hit on the perfect approach to helping people stop smoking. But according to Professor West, research has uncovered some useful facts. For example, we know that if psychological support is provided over the phone, the benefit seems to be similar in size to face-to-face support. Support on the internet is not so effective, but it’s better than no support at all. There’s also indirect evidence that support in groups may be more effective than one-to-one support, perhaps because people are less inclined to let down a group to which they’ve formed an attachment, than a therapist who is being paid to see them. Moderate amounts of physical activity may also help reduce cravings and withdrawal symptoms.
Other psychologists do advocate a particular theoretical approach. Professor David Marks, a chartered health psychologist at City University, London, developed the CBT-based Quit for Life programme, which was published by the British Psychological Society in 1993. ‘Quite a few psychologists have endorsed an approach that incorporates nicotine replacement therapy with some form of counselling. My approach is somewhat outside of the mainstream, of the NHS: I’ve advocated intensive CBT, which in my opinion is the most effective way of helping smokers,’ says Marks.
CBT for smoking aims to reduce smoking gradually over a period of seven to ten days, unlike nicotine replacement approaches, which advocate immediate cessation. CBT changes people’s experience of smoking, for example by teaching them to repeat a statement in their head while they are smoking, such as ‘This is giving me no satisfaction’. Such techniques are combined with visualisation and relaxation. Professor Marks and his colleague Dr Catherine Sykes have recently published some encouraging trials of CBT, with abstinence rates at one year follow-up being double the usual rates found with nicotine replacement therapy. However, they were unable to compare CBT against nicotine replacement therapy in the same trial and this direct comparison still needs to be performed.
A current high priority in cessation research is relapse prevention. ‘Studies have failed to find that doing extra sessions, telephone contact or other types of psychological relapse prevention after the initial treatment period (usually four to six weeks) make any difference at all to the relapse rate,’ says Professor West. ‘Maybe we just haven’t hit on the right formula, but it’s obviously more difficult to achieve than the initial cessation’. It’s not that behavioural support combined with nicotine replacement don’t translate into long-term success for many smokers: the trouble is that the relapse rate stays the same even when extra support measures are introduced to help prevent relapse.
No fire without smoke?
After 12 hours without a cigarette, smokers start to find things less rewarding, less pleasurable and they become more impulsive. That’s according to recent research by Dr Lynne Dawkins at Goldsmiths College and the University of East London. She’s tested smokers on an eye movement task, in which they’re required to glance in the opposite direction to a target that appears on a computer screen. It’s a test of impulsivity because they have to inhibit the reflexive urge to look directly at the new target. Participants were about 10 per cent poorer at the task after they had abstained for 12 hours, compared with when they had recently smoked or had nicotine replacement therapy.
‘How that translates into impulsiveness in the real world is difficult to ascertain, and it is a bit of a long step to then say this means abstinent smokers are going to find it harder to resist reaching for a cigarette,’ Dawkins says. ‘But having said that, we found that the participants who performed the worst on this task were the most likely to have relapsed seven days later.’
To test smokers’ responsivity to reward and pleasure, Dawkins has used a simple card sorting task. Participants are tested without a reward and then they’re tested with a reward of 10 pence for every five correctly sorted cards. Most people sort faster on the trials when a reward is given. Crucially, however, smokers who’d abstained for 12 hours didn’t show this response to the introduction of a reward.
So could these findings help people to quit? ‘The first thing is simply to be aware of these psychological effects,’ says Dawkins. ‘So then quitting smokers can try to be extra cautious about resisting the urges, and not falling into the trap of thoughtlessly reaching for another cigarette. In terms of finding things less rewarding, it might help to try to enhance the salience of other natural rewards, to engage in as many rewarding activities as possible. And on a positive note, we’ve found that after being abstinent for one month, smokers’ impulsivity and reward levels had returned to normal.’
Another option could be to try drinking a cup of coffee – Dawkins and colleagues have found that small amounts of coffee or alcohol both cause abstinent smokers to perform on the impulsivity and reward experiments as if they’d had a cigarette or nicotine replacement. But then again that might not be a good idea, as Dawkins explains: ‘Some people tend to make an association between having a coffee and a cigarette, so a cup of coffee may trigger a classically conditioned craving response for a cigarette.’
Hard to reach the core?
Before the associated health risks became clear, smoking was promoted and seen by many as classy and sophisticated. Or even macho – just think of the Marlboro Man alone in the desert with only his cigarette for company. However, the acceptability of smoking to society has been eroding for years, and now overnight, with the introduction of the new ban, England is going to become a far less comfortable place to be a smoker.
‘It’s marginalising smoking and that’s a significant step,’ says Dr Lalage Sanders of the University of Wales Institute, Cardiff. ‘Looking at the stats on current smokers, we know that a large number, between 60 and 75 per cent, say that they would like to give up – they’ve already accepted it’s something that they don’t want to be doing. However it’s the hardcore smokers – the “unreconstructed smokers” – who are happy to be smokers, and who have no wish to give up; they are the ones who are going to find the ban difficult to navigate.’ Indeed, a survey in England by Professor Martin Jarvis and colleagues in 2003 of 7766 adult smokers, identified a hardcore 16 per cent as matching this description.
Most of these hardcore smokers tend to be older and Dr Sanders says she believes the new ban means fewer youngsters will join their ranks in the future. ‘Although a lot of teenagers are still starting to smoke – in fact the figures have risen, while in other age groups the number of new smokers has dropped – soon it will become difficult to smoke anywhere, so I believe the ban may have its greatest effect on this younger age group. One can but hope.’
The government has said it expects a surge of around 700,000 new ex-smokers following the introduction of the English ban. Professor West believes this to be an overestimate because whereas in countries like Ireland the ban represented a big change, in England smoking was already prohibited in many public places prior to 1 July. ‘I think if the ban generates 200,000 new ex-smokers that would be very good, that would be a lot of lives saved, but it won’t be on the scale that the government are hoping,’ he says. CJ
BOX: More for research and practice
The experience of implementing smoke-free legislation in Scotland suggests that the new laws could have major impacts on attitudes, behaviours and health. But despite positive statistics in the areas of compliance, number of quitters, bar use and more (see tinyurl.com/325gfp), studies looking at the more specifically psychological aspects are only just starting to emerge.
Dr Diane Dixon and colleagues at the University of Stirling have been using the theory of planned behaviour to investigate the impact of the ban on smoking, diet, exercise and alcohol consumption. ‘The aim is to establish whether a piece of public health legislation that was specific to smoking behaviour also has a more general impact on other critical health behaviours,’ she explains. Another study, coordinated by the University of Nottingham and the University of Leeds and involving seven other universities, will use data from Scotland as a positive control group.
Professor Eamonn Ferguson (University of Nottingham) told us: ‘We will explore constructs from a number of theoretical models in social cognition, risk perceptions, emotions and personality in relation to behavioural change and symptom reporting, using data from three months pre- and post-ban. It’s a major health promotion intervention, and a great opportunity for health psychologists and others to collect data to explore mechanisms of behavioural change.’
The ban also affects practitioners (see www.bps.org.uk/rgex). The inclusion of mental health wards in the legislation has been described as ‘unrealistic and unethical’ by some organisations, and a Rampton Hospital patient is to take Nottinghamshire Healthcare Trust to the High Court under the Human Rights Act.
BOX: Pills plus?
The National Institute for Health and Clinical Excellence (NICE), the government’s independent health advisory body, gave its backing in May to a new pill that helps people stop smoking more easily. Varenicline (trade name Champix in Europe, Chantix in the USA) is reportedly more effective than both nicotine replacement therapy, and the rival drug Bupropion, in helping people achieve continuous abstinence. The new pill, which binds to nicotine receptors in the brain, helps reduce craving and withdrawal symptoms.
In its formal evaluation of the drug, NICE states: ‘Varenicline should normally be provided in conjunction with counselling and support, but…if such support is refused or is not available, this should not preclude treatment with varenicline.’
The NICE guidelines on smoking cessation are due to be published later this year. A draft is currently available: see tinyurl.com/27z4hz.
Actively tackling childhood obesity
A PSYCHOLOGY-based programme for tackling childhood obesity – ‘MEND’ – has reported sustained benefits at 12-months follow-up. Thanks to funding from the Lottery and Sainsbury’s, the MEND programme, which stands for ‘mind’, ‘exercise’, ‘nutrition’, ‘do it’, is now set to be rolled out to over 300 centres around the country.
The programme is not a diet – it focuses on teaching children and their families more healthy behaviours in a fun way. The programme’s research director, Dr Paul Sacher, a specialist paediatric dietician at Great Ormond Street Hospital for Children, said: ‘We were delighted to see that the results were largely sustained at 12 months. Obviously sustaining a healthy lifestyle is the Holy Grail of health and fitness.’
The new findings are from a randomly controlled trial involving 107 eight- to twelve-year-old moderately obese children, half of whom were put through the MEND programme for nine weeks. Earlier findings showed that three months after the intervention ended, the children on the programme showed improvements in terms of waist circumference, BMI and self-esteem compared with the children who received no intervention. At that point, the control children also began participating in the programme. The very latest findings show that 12 months after the study began, the children who initially participated in the programme still demonstrated improvements compared with their own baseline from the start of the study. The results were presented to the European Congress on Obesity in April.
Psychologist Dr Paul Chadwick created the programme with Dr Sacher and has been involved in the trial. Chadwick told us that ‘psychology is woven into the very fabric of the programme’, in terms of ensuring the whole thing is enjoyable for children, is family based, and incorporates principles of how children learn.
Chadwick said the new findings were particularly satisfying since critics of the MEND programme
had suggested any benefits were probably caused by the programme’s intensity and unlikely to last long after the programme ended. While the findings are welcome and compelling, The Psychologist put it to Dr Chadwick that the initial part of the trial lacked a treatment control, and that the 12-month follow-up lacked any control group at all. ‘It is a big thing in obesity research that people want to set a complex behavioural treatment against some other intervention to prove that the behavioural treatment works, but it’s actually pointless to do that,’ he retorted. ‘Nobody wants the non-behavioural treatment so it’s very hard to recruit into standard treatment, such as simple dietary advice. We also know that standard dietary advice doesn’t really work. In fact, of people who opt into a control group of dietary advice, 75 per cent will tend to drop out within the first three sessions.’
He continued: ‘These new findings show that there does seem to be a shift in parenting practice and the children’s behaviour that is sustained. This suggests the behavioural element of the programme is an active ingredient – that the changes are not just an artefact of the exercises performed during the programme.’ CJ
Improving access to psychological therapies
THE Improving Access to Psychological Therapies project, which began last year in Doncaster and Newham, is to be expanded to 10 further sites across England. The news came with Health Secretary Patricia Hewitt’s announcement of a further two million pounds investment in the scheme.
'The demonstration sites are showing early signs that if you provide quick access to therapy services, the time that patients are ill is reduced and individuals are better able regain their independence – for example by getting or keeping a job,’ the Health Secretary said.
At Doncaster, graduate mental health workers,
under the supervision of a psychologist, provide low-intensity CBT to people with problems like anxiety and depression. The Newham site provides a comprehensive CBT service delivered by CBT-trained therapists. Over the 2006/7 period the two sites will have supported more than 5000 people.
Following the arguments advanced by Lord Layard and others, the effectiveness of the scheme is being
assessed not only in terms of improving people’s well-being but also in terms of whether people are able to return to work and stay in work. The idea is that by improving people’s capacity for work, a nationwide network of psychological treatment centres would in effect become self-financing.
Responding to the expansion of the scheme, Society President, Professor Pam Maras said: ‘We welcome any opportunity for qualified applied psychologists to make significant contributions in the expansion of evidence-based psychological therapies, and to deliver those services in ways that guarantee high-quality and effectiveness for all mental health problems.’ CJ
- For a critical view on Layard’s proposals, see the article on p.422.
RESEARCH FUNDING NEWS
The Stroke Association is awarding Research Project Grants up to a maximum of £60,000 per annum for three years. They are particularly interested in receiving project applications related to stroke prevention, acute treatment, assessment, ethnic factors, epidemiology, rehabilitation, psychology and stroke in people of working age. The next closing date for applications is 20 July 2007.
- Further details: tinyurl.com/39aevv
The Harry Frank Guggenheim Foundation provides grants for research proposals from any of the natural sciences, social sciences and the humanities that seek to increase understanding of the causes, manifestations, and control of violence, aggression and dominance in the modern world. Research into violence, aggression and dominance in relation to social change, the socialisation of children, intergroup conflict, crime, family relationships, and the control of aggression and violence are of particular interest to the Foundation. Grants, from £7500 to £15,000, are made to individuals for individual projects. The deadline for applications is 1 August 2007.
- Further details: www.hfg.org/rg/guidelines.htm
The National Institute for Health Research (NIHR) Health Services is offering Competition 4 of the Research for Patient Benefit programme (RfPB). The programme funds research that
l is related to day-to-day practice in areas identified and developed by health service staff;
l includes high-quality academic input; and
l is of relevance to the broader NHS.
Projects can be either quantitative or qualitative, and should aim to
l study the way that NHS services are provided and used;
l evaluate whether interventions are effective and provide value for money;
l examine whether alternative means for providing health care would be more beneficial in terms of cost and effectiveness; and
l formally assess innovations and developments in health care which will benefit patients.
Joint applications from NHS researchers with academic partners as co-applicants are particularly welcome. Projects can run for one to three years, and the normal level of funding is approximately £250,000. The closing date for Competition 4 registration of Intention to Submit is 10 August 2007 (Submission deadline is 21 September).
- Further details: www.nihr-ccf.org.uk/site/programmes/rfpb/default.cfm
The Leverhulme Trust provides funding to support international academic research via the following schemes:
Academic collaboration: International Networks that aim to develop fields of research where the participant can benefit from an international exchange of ideas and experience between two or more institutions and establish an effective research network.
Visiting Professorships: to enable universities to host internationally distinguished academics from overseas in order to enhance the research skills and work of the host institution. Visits should be between three and ten months. The next closing date 15 October 2007.
- Further details: tinyurl.com/2nwx72
SPECIAL ISSUE HONOUR
SOCIETY member Professor Mark Griffiths has had a special issue of the International Journal of Mental Health and Addiction (tinyurl.com/2dw7zq) devoted to him and his work.
Editor-in-chief Masood Zangeneh said: ‘As a prolific writer, Mark Griffiths has shaped our views about the science of human behaviour through his diverse contributions. As an academic avant gard, Griffiths has helped to bring unnoticed psychological and social issues to the forefront of public debate. He has also contributed significantly to the development of paradigms to explain these issues.’
Professor Griffiths said: ‘As this kind of honour is normally given to someone who is in the twilight of their career, or dead, I feel especially honoured.’
MENTAL CAPACITY ACT CODE PUBLISHED
THE Code of Practice for the Mental Capacity Act 2005 has been published by the Department of Constitutional Affairs. It will provide guidance on how the provisions of the Act will work for those caring for, or working with, people lacking mental capacity. The Code incorporates good practice and case studies, and demonstrates how the principles of the Act can be applied flexibly in particular circumstances.
- The Code is available from The Stationery Office (www.tsoshop.co.uk), priced at £15.00.
PSYCHOLOGIST HITS YOUTUBE NUMBER ONE
PSYCHOLOGIST Richard Wiseman (University of Hertfordshire) has created a psychology-based clip for the video-sharing website YouTube. It reached the number one spot and has had over one million views. Watch or download via www.richardwiseman.
com/quirkology/stuffvideo.html. Wiseman said: ‘I think that YouTube offers a huge potential to bring psychology to new audiences – the success of the clip shows there is an appetite for this type of material and it is a great way of getting people interested in the subject.’
The things that children do
CHILDREN aged between five and six can solve approximate addition and subtraction even before they’ve been taught any formal arithmetic skills. Camilla Gilmore of the University of Nottingham and colleagues say their finding has implications for the way children are taught.
The researchers tested children who had mastered verbal counting but who had yet to receive any formal arithmetic tuition. They presented them with problems like: ‘Sarah has 15 candies and she gets 19 more. John has 51 candies. Who has more?’ The children performed with between 64 and 73 per cent accuracy, which shows they weren’t just randomly guessing.
So how were the children doing this if they hadn’t yet been taught the logic of the symbolic number system? The researchers believe the children were drawing on a non-symbolic sense of number, of the kind that even some animals have been shown to have. This non-symbolic number sense is what allows us, for example, to identify at a glance which of two arrays of dots is the larger.
In support of this theory, the children were unable to solve maths problems that required an exact solution or that required an exact representation of number. Moreover, the children’s performance showed two key features, both of which have been previously associated with a non-symbolic sense of number: their accuracy dipped as the ratio of the numbers to be compared approached one, and their performance at addition was more accurate than their performance at subtraction.
Co-author Elizabeth Spelke at Harvard University said: ‘We’ve known for some time that adults, children, and even infants and nonhuman animals have a sense of number. We were surprised to see, however, that children spontaneously use their number sense when they’re presented with problems in symbolic arithmetic. These children haven’t begun to be taught place value or exact addition facts. Nevertheless, their natural sense of number gives them a way to think about arithmetic.’ The findings are published in the journal Nature (tinyurl.com/2pqrbn).
In a separate development, researchers have shown that babies aged between four and six months are able to tell, when watching a silent video, whether someone has switched languages. However, it’s a skill they lose by the age of eight months, unless raised in a bilingual environment.
Whitney Weikum and colleagues played 36 babies the same silent video of a person’s face as they said a sentence in one language (English or French), over and over again, until the babies grew bored of it and stopped looking at it so much. Next they played them a test sentence which featured the same speaker uttering a new sentence in a new language. They compared how long the babies looked at this video with how long they looked at a control video featuring the same speaker, a new sentence, but the same language as in the video they’d grown bored of earlier.
If the babies looked longer when the language had switched than at the control video, this would strongly suggest they had registered something different was going on when a new language was spoken – even though there was no sound. And that’s exactly what the researchers found: four-month-old and six-month-old babies looked longer at the new silent videos when the language being spoken had changed. Eight-month-old babies didn’t register the change in language, unless – as a second experiment showed – they were being raised as bilingual.
This study, published in Science (tinyurl.com/25eryy) provides the latest example of a discriminatory ability that we start off life with, but then lose, as we adapt to our environment. Other examples include the ability to discriminate consonant and vowel sounds from foreign languages, to discriminate rhythms from other cultures’ music, and to distinguish between the faces of individuals within a given animal species. CJ
PSYCHOLOGIST Brooke Feeney of Carnegie Mellon University has been awarded £6000 by the London-based personal development consultancy Mind Gym, as winner of their inaugural Academic Prize.
Feeney won her prize for a paper published earlier this year in the Journal of Personality and Social Psychology. Her experiments demonstrated that ample, unconditional support by one person towards their partner, leads that partner towards greater independence, not increasing neediness – an effect Feeney dubs the ‘dependency paradox’.
Feeney told us: ‘In many Western cultures, dependence on others is often viewed as a sign of weakness and as something that should be discouraged. But this research provides support for an alternative view of dependence on others, which is that true independence and self-sufficiency emerges because of an individual’s ability to depend on close relationship partners in times of need. People are able to engage in more activities, accomplish more goals, use their minds better, and function more autonomously when their dependency needs are supported.’
Feeney said her findings have huge potential for application. ‘For example, organisations could learn to function as a secure base from which their employees are able to function to their optimal potential,’ she said. CJ
- Mind Gym is inviting entries to their 2008 prize. See www.themindgym.com/academicprize.
PSYCHOLOGISTS have developed a tool that’s been found to improve the accuracy of eyewitness memory.
After an incident, the police will often take only a few details from witnesses, with full statements sometimes not given until several weeks later. By this time substantial memory decay will have occurred. By contrast, the Self-Administered Interview (SAI) is designed to be filled out by witnesses immediately after an incident. Drawing on the memory-enhancing principles of a full cognitive interview, the SAI prompts witnesses to recall every small detail of what they’ve seen and to recreate the context of the incident.
Initial tests at simulated crime scenes have shown that participants using the SAI were able to recall relevant information that was 42 per cent more accurate than information provided by control witnesses using simple free recall. Moreover, seven days after a simulated crime, participants using the SAI recalled 30 per cent more correct details.
The SAI was developed by Dr Fiona Gabbert (University of Abertay), Dr Lorraine Hope (University of Portsmouth) and Professor Ron Fisher (Florida International University). Dr Hope said that recalling an event before any substantial forgetting has occurred may ‘serve to “freeze” the memory against the course of natural forgetting’. CJ
Teenagers whose parents buy them alcohol are less likely to binge drink and less likely to drink in public places. That was the finding of a cross-sectional survey of over 10,000 15- to 16-year-olds in the North West of England. Writing in the open-access journal Substance Abuse Treatment, Prevention, and Policy, Professor Mark Bellis and colleagues concluded: ‘Such findings suggest that parental provision of alcohol, at least to youths who already consume, may reduce their immediate risk of hazardous and harmful consumption behaviours.’ Paradoxically, the findings came shortly after the charity Alcohol Concern called for the prosecution of parents who provide their under-15-year-olds with alcohol. CJ
New fellow of the Royal Society
PROFESSOR Barry John Everitt (Department of Experimental Psychology, University of Cambridge) has been elected as a Fellow of the Royal Society. Professor Everitt is distinguished for research that has helped to introduce a new way of addressing the neural basis of motivated behaviour by linking learning theory with the methodology of systems neuroscience. He has defined the functional organisation of the limbic-striatal circuitry that mediates Pavlovian and instrumental learning processes.
Identifying teenagers at risk of self-harm
DISTRESSED teenagers who plan to deliberately injure themselves (‘self-harm’) often conceal their intentions for fear of unwanted treatment, or because they find it difficult to articulate their feelings. Now Harvard-based
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