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Behavioral determinants with the largest effects are often those related to the environments in which behaviors occur. This suggests the merits of a shift in focus of changing behavior at scale away from interventions based on deliberation and decision-making and toward interventions that involve changing cues – physical, digital, social, and economic – in environments. This chapter focuses on changing cues in small-scale physical environments – sometimes known as choice architecture or nudge interventions. Despite attracting much interest, these interventions have been little explored from a theoretical perspective. Exploring the mechanisms by which some of these interventions exert their effects provides a starting point. Examining evidence of three interventions – increasing availability of healthier food options, reducing glass size, and putting warning labels on food and alcohol products – suggests no single theory explains their effects. The mechanisms by which these interventions affect behavior change also necessitate different levels of explanation and demand a theoretical framework that applies at different levels. Recognizing the distinction between model-free and model-based learning and behavior may be central to this. Advancing knowledge on changing behavior by changing environments requires robustly designed field studies to estimate effect sizes, complemented by laboratory studies testing mechanisms to optimize interventions and develop theoretical understanding.
Despite a lack of empirical evidence, many smokers and health professionals believe that tobacco smoking reduces anxiety, which may deter smoking cessation.
The study aim was to assess whether successful smoking cessation or relapse to smoking after a quit attempt are associated with changes in anxiety.
A total of 491 smokers attending National Health Service smoking cessation clinics in England were followed up 6 months after enrolment in a trial of pharmacogenetic tailoring of nicotine replacement therapy (ISRCTN14352545).
There was a points difference of 11.8 (95% CI 7.7-16.0) in anxiety score 6 months after cessation between people who relapsed to smoking and people who attained abstinence. This reflected a three-point increase in anxiety from baseline for participants who relapsed and a nine-point decrease for participants who abstained. The increase in anxiety in those who relapsed was largest for those with a current diagnosis of psychiatric disorder and whose main reason for smoking was to cope with stress. The decrease in anxiety on abstinence was larger for these groups also.
People who achieve abstinence experience a marked reduction in anxiety whereas those who fail to quit experience a modest increase in the long term. These data contradict the assumption that smoking is a stress reliever, but suggest that failure of a quit attempt may generate anxiety.
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