Rethinking Prevention: Testing Implicit Retraining for Public Health Purposes

A large number of smokers is unmotivated to quit smoking: 40 % are not motivated to quit within one year, 14% are not willing to quit within six months, while 22 % is not planning to quit at all. Current smoking cessation programs do not focus on smokers who are unmotivated to quit smoking. Yet, Dutch smoking prevalence rates remain quite stable (28%) and targeting smokers unmotivated to quit is essential in order to further decrease the prevalence, morbidity and mortality of smoking. Several studies analyzed which motivational beliefs underline the decision to quit smoking. They found that smokers are unmotivated to quit because they are unaware of or underestimate the negative outcomes of smoking and/or have low self-efficacy regarding quitting smoking. Smokers unmotivated to quit perceive more positive than negative outcomes of smoking and have lower levels of self-efficacy compared to smokers who are motivated to quit . Persuasion, however, may not be the most optimal change strategy to influence smokers unmotivated to quit. Especially, as smokers who are unmotivated to quit avoid reading, talking and thinking about their risk-behavior. We, therefore, propose an alternative method: implicit retraining strategies targeting implicit tendencies. Perceived pros and cons of smoking as well as self-efficacy are likely to be subject to implicit biases such as approach-avoidance biases and attentional biases. This implies that smokers may be implicitly attracted by the pros of smoking, thus explaining the absence of actual motivation to quit. Regarding self-efficacy, Bandura has stated that smokers with low levels of self-efficacy tend to avoid high-risk smoking related situations – a tendency which can also be measured implicitly by assessing approach-avoidance biases. Two approaches can be used to target implicit associations: approach-avoidance bias retraining or attentional-bias retraining. First, approach-avoidance models imply that individuals tend to approach positive stimuli (in this proposal e.g. the perceptions of advantages of smoking) and are inhibited in avoiding them (and vice versa with negative stimuli). Attentional biases indicate that individuals have more attention for salient stimuli, i.e. the pros of smoking. Consequently, stimuli representing the pros of smoking will facilitate approach biases and attentional biases among smokers who are unmotivated to quit smoking. Regarding self-efficacy, it can be expected that high-risk smoking related situations evoke avoidance biases and attract less attention compared to low-risk situations. Consequently, these smokers are more likely to profit from implicit strategies helping them to change their focus from pros to cons of smoking and to master high-risk smoking related situations (=increasing self-efficacy) This proposal aims at testing the efficacy of a new behavioral change strategy for smokers focusing on retraining implicit tendencies in order to reach and change levels of motivation in smokers unmotivated to quit. We will use principles of recently developed retraining programs. We aim to identify the relevant stimuli for developing a program aimed at retraining implicit biases underlying the pros and cons of smoking and self-efficacy using an implicit pictorial retraining program (IR). We will assess new delivery modes of the implicit retraining by packaging them as games in order to increase acceptability by LSES groups. We will compare these effects with traditional persuasive computer tailored methods. We will focus on low-SES groups as they are at higher risk of smoking continuation and as they may benefit more from implicit approaches using pictures. Study 1 aims at generating a set of standardized picture pairs matching a cognition-related picture (pro of smoking, con of smoking, high-risk smoking related situations (=self-efficacy related) to a contrast category (e.g. high risk smoking related situation matched to low or no-risk situation). This identification is needed for building a valid retraining program. Study 2 aims at identifying the best retraining method (approach bias retraining or attentional bias retraining) for targeting pros and cons of smoking and self-efficacy. Study 3 aims at testing whether packaging the implicit pictorial retraining tasks as games is favorable by assessing user experiences with the games compared to the user experiences with a standard format of the tasks. Study 4 integrates the obtained results in a RCT and tests the effects of implicit pictorial retraining, compared to two control conditions: 1. computer tailored messages (persuasive) and 2. no intervention. We will also conduct a cost-effectiveness evaluation. Implementation of the new approaches will occur with Health Education Authorities (GGD-en) and national organizations such as the Dutch Smoking and Health Foundation and the Dutch Cancer Society.