Lessons for health behaviour change campaigns?
After 13 years of heavy smoking and many attempts to quit I finally managed to smoke my last cigarette on 19 December 2015. I have since gone over 500 days without heeding the little evil voice in my head (“Just one more!”). I am incredibly proud as quitting smoking has possibly been the hardest thing I’ve ever done in my life. But it’s possible to do it and anyone else can do it too. So let’s see what helped me chuck all my lighters in the bin and bring about the biggest health behaviour change of my life. And how this fits with behaviour change theories.
People are inherently influenced by what others around them think. This probably played a role for me too. On moving to the UK it was a bit of shock that it was ‘abnormal’ to be a smoker in my age group rather than the other way around, as in Hungary. Also some of my closest friends were giving up smoking and I genuinely envied them for being smoke free and having a healthy radiance. The constant pleas from them to quit as well as from my boyfriend and mom also influenced me. These ‘Normative Appeals’ – facing up to the fact that the normal thing to do is not to smoke and that people around me expect me to quit – were a big push to make the change.
Health Belief Model
The Health Belief Model is pretty much weighing up the costs (in this case, the awful withdrawal symptoms), and benefits (in this case, too many to list) of making the change, how likely these were to happen and how serious the consequences would be, on quite a rational level.
As far as I am concerned, completely true. The information I came across on the benefits of stopping smoking used to be quite general (along the lines of “You will be less likely to get cancer”). They made me aware that it is unhealthy to smoke and that I should quit, but they were too intangible. I wasn't prompted to actually make the effort to kick the habit and keep it up when it is hard. The same way “Smoking can kill” on the cigarette box with the horrible pictures felt too distant to apply to myself there and then, so I looked for a trendy cigarette box on e-Bay rather than quitting.
Then one day I came across a chart on what happens to your body after you smoke your last cigarette - in 20 minutes, 8 hours, 48 hours and so on. That really struck a chord. The chart stayed with me through the darkest moments of my journey. Fighting to reach the 8-hour mark to enjoy normal oxygen levels, and the 48-hour mark for the satisfaction of knowing there is no more hated nicotine in my body and to see if my taste and smell will really improve, was easier than just generally fighting for better health later on. It made my progress specific and achievable and it felt like all that suffering was worth it because it had a tangible result.
Similarly, in the first few weeks of quitting I had the opportunity to measure my carbon monoxide level by a simple breath test. It was incredibly satisfying to see the numbers on the screen showing how it was decreasing week on week and to understand how oxygen can now take over carbon monoxide’s place in my red blood cells, making it easier for my heart to work and less likely for me to give out ridiculous noises when walking up the escalator at Oxford Circus (which is really not cool for a twenty-something year old). Specific, tangible, and even (in)audible.
Another tangible benefit was not handing over an eye-watering amount of money to tobacco companies. I made the promise to myself that if I make it to the 3-week mark I will buy a gift to my mom and dad, something they would really like but they would not buy for themselves. My mom got a nice summer dress and my dad a couple of nice handkerchiefs and a note that they are the tangible evidence for me having quit smoking for good. They were over the moon, which made me feel extremely good too.
Seeing my progress through the time milestones and decreasing carbon monoxide levels was also very important, especially when I needed convincing stuff to tell myself during strong urges. The belief that you can do it, which is called self-efficacy, is a powerful motivator to make a start on quitting and to keep it up when it hurts the most. Why bother if you are unlikely to reap the benefits?
As time progressed this belief just got stronger and stronger as I saw my carbon monoxide levels decreasing and I was clocking in time milestones with the same joy as collecting coins when travelling through Mushroom Kingdom with Super Mario in the 1990s. It is also one of the main principles of Cognitive Behavioural Therapy (CBT) that you need positive thoughts and interpretations to replace the negatives that are holding you back.
After each ‘first’ risk situation I survived without lighting a cigarette – the first morning, the first time someone offered me a cigarette, the first argument, the first time I was exhausted, the first time meeting up with smoking friends (I did skip many social events just to avoid this!), the first article written (I had the habit of smoking after each section), the first time drinking alcohol, the first conversation with someone smoking a cigarette right in front of me - it helped me feel even more convinced that this time I will make it.
Also, I had lots of positive case studies around me to encourage me including my closest friends, who had successfully quit before I did. This, combined with thinking that lighting a cigarette would flush all the efforts and suffering I went through down the toilet, being unable to reap the benefits of my arduous effort, kept me going.
‘Cues to action’ theory
Research from Health Action Campaign shows that people with less motivation to change their behaviour sometimes experience trigger points in their lives when they are more likely to make changes. These can include getting married, having children, or a loved one developing serious health problems. These events can serve as a cue to action. In my case I had just finished university, had started my career and was in a serious relationship with a view to potentially have children in a few years’ time. So I felt settled and I was planning to quit at some point. My cue to action was a leaflet advising that my workplace was launching a free stop smoking clinic through the NHS. This was my time.
The weekly sessions gave structure to my attempt to quit, and suddenly it mattered because having signed up I was accountable to my counsellor, and I was expected to quit there and then by her, the people around me and indeed myself (hello Normative Belief!). My awesome counsellor also kept telling me I would make it because I was approaching it in such a determined way and I believed her (hello Self-efficacy!). She provided the carbon monoxide device and took my levels every week to show my progress, so I had something positive to focus on (hello Cognitive Behavioural Therapy!) and I was seeing very tangibly how I was already reaping the benefits (hello Health Belief Model!).
People tend to favour immediately enjoying something as opposed to long term benefits. This isn’t a friend to people trying to stop smoking. When you are having a strong urge to smoke, and the little evil voice in your head is throwing a tantrum shouting “Just one more!”, it is extremely difficult for your brain to come to terms with the thought that “I know I could ease this horrible feeling very simply but I won’t do it because I am working towards long-term benefits.” However, if you know this, it is easier to counteract it. I measured how long the urge pikes lasted, so I knew that most of the time I just needed to survive a couple of minutes and I would be fine. Yes, it did happen a few times that I was literally staring at a clock for 2 minutes, and it worked.
And there is a trick too. Luckily, we are also more motivated by the prospect of losing something we already value than by possible future gain. In my case, by smoking a cigarette I would have been risking losing my 24/48/72/96/1000 hours clocked which I was very proud of. I was risking losing my finally healthy carbon monoxide levels. I was risking losing my sense of achievement and people’s recognition of my efforts. I was risking the right to loudly declare that I don’t smoke anymore when offered a cigarette. I was risking losing all ‘my firsts’ I survived without a cigarette. Most of all, I was risking losing the belief that I am ever able to quit smoking, after all those attempts when I didn’t manage. So start counting now!
Zsuzsanna Matyak May 2017
Continue the conversation with us on Twitter - @Health_ActionUK