Health psychology

Health psychology investigates how and why people behave in unhealthy ways and what can be done to
encourage people to adopt a healthier approach. It combines different elements of psychology: the biological
bases of behaviour, how our cognitions (thoughts} affect our behaviour and social influences on health-related
behaviour. Health psychologists work to understand why people engage in harmful activities, such as drug
taking. so that they can help by introducing strategies to reduce or prevent such activities.
In this topic, you will learn about:
issues around drug taking
biological and learning explanations for alcohol, heroin and nicotine addiction
• treatments for drug addiction, including an anti-drugs campaign and the psychological strategies behind it
• individual differences in drug misuse and how drug misuse may develop
• research methods used within health psychology
• research studies that examine key aspects of health psychology
• a key issue around the topic of health psychology that is of relevance to society today
• how to carry out a practical research exercise relevant to topics in health psychology
• wider issues and debates in health psychology (A level).

8.1 Content
Learning outcomes
In this section, you will learn about:
addiction, tolerance, dependency and withdrawal in relation to drugs
a biological and a learning explanation for alcohol. heroin and nicotine addiction
two treatments for addiction
how and why anti-drugs campaigns are used
• biological and social factors influencing individual differences in drug misuse
• how social influences d uring development can lead to drug misuse.

Drug-taking behaviour
Drugs can mean illegal substances, such as, heroin but can also refer to legal substances used by many, such as
alcohol. and the nicotine found in tobacco. These drugs can become addictive, creating a feeling in the person that
they need the drug. If they stop taking the drug this can result in withdrawal symptoms.

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Addiction
Addiction is a condition that occurs when a person ingests a substance (for example drugs, alcohol
or nicotine) that they find enjoyable, but the continued use of the drug can interfere with ordinary
life responsibilities, such as work, relationships or health. Drug users will feel an increasingly
overwhelming need to continue to use the drug, which can result in a person becoming overly
focused on the drug use, and this is how it can cause problems in other areas of their lives. A drug
user may believe that they have to have the drug and cannot function without it Those who are
addicted to a drug may find it difficult to stop the behaviour, even if they know it is causing them
harm or creating difficulties.

Addiction can present itself in a physical way, where a person shows physical symptoms if they do
not get the drug, resulting in physical dependency. Addiction to a drug, however, goes beyond the
body's physical desire for the drug or a physical reaction; it can also cause a psychological need for
the drug. In order to fully understand addiction, it is necessary to consider the cognitive, biological
and social processes that contribute to the behaviour, and how these processes are influenced by ~ Key terms
using the drug. This contributes to the dependency that can occur.
Nucleus accumbens: an
It is important to remember that the effect of addiction, including withdrawal symptoms and
area of the midbrain
dependency, differs depending on the drug that the person is taking.
associated with the brain's
reward system.
Dependency
Ventral tegmental area:
Psychological dependency an area of the midbrain
People typically continue to take drugs because of the psychological effects they experience when associated with the brain's
they take them. Drugs may affect their feelings, reactions and behaviours in situations. Some people reward system and the
may report, for example, that they feel more confident, relaxed or more able to achieve certain origin of dopaminergic
goals as a result of taking their specified drug. Repeated use of the drug can lead to a psychological activity.
dependence on the drug, as the person believes they cannot manage without taking it. They
therefore continue to take the drug.
Exam tip
Physical dependency Dt ve oc no a famr rar ty
Drugs have an effect on how the body works by changing the way neurotransmitters operate in the •'· tr ~he fT'ea~n'3 of the
brain. For example, heroin increases the amount of dopamine in the reward pathways of the brain tt·rr·"l•, 'to,erarce'.
(the nucleus accumbens and ventral tegmental areas) by boosting the activation of dopaminergic ·,_,"ltho.ra•A'a ·and
·dependency'
synapses, causing an intensely pleasurable or euphoric experience while it lasts. People may,
(p-;ychologre<JI and
therefore, continue to take a drug because it has a pleasant physical side effect. Repeated use of
phy<>rological), and oerng
drugs creates a physical dependency as the brain adapts to the changes imposed by the drug so that a!:>lf' to apply them vvhen
it no longer operates normally without it. Abstinence from the drug can result in unpleasant physical <.xplain:,g :ou!:>?tance u?e
side effects. wrll ht-'lp to <oilow your
lnowledge of the topic.
Two important aspec ts of physical dependency are tolerance and withdrawal. Thi? can be ach:eved by
cr1,,1ting either a glo??ary
Tolerance: This occurs over time as a person continues to take the drug. The body adapts to the
o f term'>. which can be
presence of the drug and as a result needs to take greater amounts of the drug in order to get the add~ed to when a new term
same effect. This often occurs because the nervous system increases the number of receptor sites "· rntroduced. or a
for the drug molecules in a process known as up-regulation. vocabulary book. It wi 11
,Jiso hdp to avoid any of
• Withdrawal: This is experienced when the person stops taking the drug. These are painful or th<' dr5tre"" that can
unpleasant physical symptoms that the drug user will experience as the drug leaves their body h,lpp~e~ rn an exam when

or wears off. Symptoms may include vomiting, shaking and headaches or fits. The symptoms, you come aero'>'> a term
that you are t''>'> 'a'Tlilia·
the severity of the withdrawal and how quickly they are experienced depend on the type of drug
taken, and the frequency and quantity of the drugs being taken.
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Why do people become addicted to drugs?
People start to take drugs for many reasons. Addiction is what innuences a person to carry on using
drugs. Addiction can occur due to physiological and psychological changes in the individual as a
result of taking the substance. Two key explanations relate to the biological and learning approaches
already covered in this book (see Topic 3: Biological psychology and Topic 4: Learning theories
respectively). Theories within these approaches provide differing explanations for why people
continue to misuse substances, even in the presence of any unpleasant side effects of drug use.

Biological explanation: the role of neurotransmitters

Biological explanations for addiction suggest that there are key physiological innuences within our
For more information on bodies that make it more likely that a person will engage in substance use and how someone deals
synaptic transmission and with dependency and withdrawal. This would form the nature side of the nature-nurture debate that
the effect of recreationa l you have visited in previous topics.
drugs on the tra nsmission
process in the central WIDER ISSUES AND DEBATES
nervous system, see Topic 3:
Biological psychology. Nature-nurture
The nature-nurture debate suggests that an individual may engage in drug ta king because of
influences from the environment, for example learning to associate a drug with pleasurable
feelings, or observing others taking drugs (nurture), or as a result of physiologica l changes that
make individuals more susceptible to drug use (nature).

Drugs will create one of two reactions in the brain of the user. This is due to the effect the substance
has on the availability of one or more neurotransmitters. Drugs will affect the body by either having
an agonist role or an antagonist role. They can also act as reuptake inhibitors. The way in which a
drug changes the anatomy or function of a cell is known as the 'mode of action'.
Agonists are drugs that mimic neurotransmitters. They fit onto receptor sites, making the post-synaptic
~ Key terms • dendrite believe that the drug is a neurotransmitter and this makes the neuron fire. Substances that act
as agonists make the stimulation of one neuron by another much easier. Using stimulants can result in
Agonist: a substance that temporary alertness and increased levels of energy. It can also create an increased body temperature
acts like another substance and an irregular heartbeat Both heroin and nicotine are agonist substances.
and, therefore, stimulates
Antagonists are drugs that bind onto receptor sites on a neuron and prevent it from firing. This then
neural action.
prevents the message being passed from neuron to neuron. Substances may act as a depressant
Antagonist: drugs which and will slow the brain's activity down. As the brain activity is reduced, the transmission of messages
produce an antagonist between neurons becomes less effective. Alcohol is considered to be a depressant. This can resu lt in
effect bind to the receptor poor concentra tion, sluggish behaviour, confusion and slurred speech.
sites on neurons to
Reuptake inhibitors are drugs that work by binding onto the axon term inal branches. This prevents
prevent the substance
the axon terminal from taking up the excess neurotransmitter left over in the synapse, ca using an
from being absorbed in
excess of that neurotransmitter. For example, cocaine is a reuptake inhibitor for the neurotra nsmitter
large quantities, therefore
dopamine. When the axon terminal cannot take up the leftover dopamine, and the dendrite from th e
reducing the effect of the
neurotransmitter. next neuron has reached its threshold, we are left with too much dopamine, causing the stimulating
effects of cocaine.
Depressant: a drug that
reduces the ability of the Alcohol
synapses to work effectively. Alcohol is a drug that is consumed in liquid form. The type of alcohol that is in alcoholic drinks is
so slowing down brain
called ethanol and it is made from plant material. Grains, fruit or vegetables are processed and
activity.
allowed to ferment for differing amounts of time, which affects how much ethanol and, therefore,

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alcohol is in the drink. Alcohol is a substance that is legal in Britain for individuals over the age of 18
years. Many people drink alcohol.

Psychological effects
Alcohol reduces inhibitions as it targets the social control areas of the brain. Reduced effectiveness
of these inhibitory mechanisms leads initially to relaxed, confident behaviour but can develop into
exhibitionism and extreme behaviour at higher levels. Users may experience relaxation following a
drink, which makes continued drinking more appealing. People who drink alcohol to avoid worrying
about personal problems may find that the reduction in stress is positive, and they start to use
alcohol as a way of coping with stress and worries. With increased use, the alcoholic becomes
psychologically dependent on the alcohol, as they see it, albeit inaccurately, as a way out of their
problems.

Physical effects
Initially, following a low intake of alcohol, users will feel warm and look flushed as a result of
the alcohol causing blood vessels to dilate. The effect of alcohol on the GABA (an inhibitory
neurotransmitter) becomes noticeable as reactions to situations slow down. Alcohol also affects
~ Key term
GABA (gamma-
•
aminobutyric acid): this is
speech, making it more difficult to form coherent words. As the fronta l lobes become depressed, they a very important inhibitory
will show less control over motor skills or coordination. Dehydration occurs when the alcohol inhibits neurotransmitter. It makes it
the hormone contro lling urination so as alcohol levels start to fall, there is increased urination. more difficult for messages
to be transmitted across
There can be many long-term health problems as a result of alcohol misuse. Key issues include liver
synapses. and is, therefore,
disease and nerve damage. The brain can also be permanently affected. Some individuals may
known as a depressant.
develop Korsakoff's syndrome. a brain disorder associated with heavy alcohol use that is characterised
by short-term memory loss and poten tial changes to their personality. Pregnant woman are advised
not to drink alcohol during pregnancy, as this increases the risk of foetal abnormality.

Mode of action
Alcohol affects neurotransmission in various ways, including GABA receptors, and reduces serotonin
activity. Serotonin is associated with emotions. A low level of serotonin in the brain can create
feelings of depression. Alcohol is, therefore, considered a depressant as it reduces serotonin levels
and can make the person feel low in mood.

Alcohol also makes GABA more effective. GABA is an inhibitory neurotransmitter that makes it
difficult for messages to be transmitted from one synapse to another. The presence of alcohol further Taking it further fl
slows down the speed at which messages are passed between neurons. This includes slowing down
fight or flight reflexes that are usually triggered by noradrenaline synapses. The nerve endings of Alcohol is a factor in many
accidents, including car
these noradrenalin synapses are numbed by the alcohol so are less effective. It also makes inhibitory
accidents. Research some
systems of the brain less effective. so people under the influence of alcohol are likely to take more
of the accident statistics
risks than they wou ld do when sober.
to see which ones involved
Tolerance alcohol. The Home Office
Short-term tolerance can develop quickly. This can lead to people feeling more sober than they website may be able to help
actually are when their blood alcohol levels drop slightly. This often contributes to behaviours such as with this. Al ternatively, look
people believing they are safe to drive a car after drinking alcohol. in your local newspaper and
see how often alcohol (or
In a matter of weeks, a regular drinker will have developed a tolerance to alcohol, as a direct result of
any other drug) is reported
the body producing more of an enzyme that breaks down alcohol quickly. As a result. a higher level
as being present in road
of alcohol intoxication will be required to reproduce the initial reactions to alcohol. The person is also
traffic accidents or incidents
likely to develop ways of dealing with the side effects of intoxication, such as drinking first thing in a
of violence.
morning to reduce the shaking symptoms of withdrawal.

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Withdrawal
Withdrawal can be felt as early as two hours after the last drink, depending on the amount
WIDER ISSUES consumed. It is typically experienced 6-12 hours afterwards. Symptoms may include shaky hands.
AND DEBATES
nausea. vomiting. headaches or insomnia. There may be some vivid dreaming or visual or tactile
Reductionism hallucinations that usually end within 48 hours.
Biological explanations for 'Alcohol withdrawal syndrome' is potentially life threatening. It can happen when people who have
drug misuse focus on the been drinking heavily for a long period of time suddenly stop or significantly reduce their alcohol
role of neurotransmitters, consumption. When they stop drinking, the neurotransmitters that have been suppressed come to
how they are affected and
the fore. As they rebound, it can create hyper-excitability in the brain. People with a heavy history of
altered by drug use. This can
alcohol use may experience delirium tremens (DTs). With DTs the brain becomes used to the effect of
be viewed as a reductionist
alcohol on GABA receptors. As alcohol levels drop, the fight-flight mechanism is overly active, and this
approach as drug taking is a
produces hallucinations, confusion or anxiety and severe tremors. DTs can be fatal and is considered
behaviour that occurs within
a medical emergency. Mortality rates can be up to 35 per cent unless treated. reducing to 5 per cent
a social context, with other
with early recognition and treatment.
drug users or at a party,
wh ich can explain the use of
drugs and their differential
Heroin
effects in other contexts. Heroin. or diacetylmorphine, is an opioid analgesic that is found naturally in the opium poppy.
The biological explanations Historically. it has been used legally as a form of pain relief in the fo rm of morphine. It is also used
tend to ignore contextual as an illegal recreational drug in which users aim to seek feelings of euphoria following consumption.
effects on drug taking and Heroin is a highly addictive drug.
experi ences. Psychological effects
Heroin rapidly produces a feeling of euphoria. The analgesic effect gives a feeling of calm and
aches or pains will disappear. The intensity of the euphoria and well-being experienced by the user
depends on the amount of heroin that has been taken. It is this feeling that ac ts as a reinforcement
or motivator to use heroin again in the future.

Psychological dependency can occur as the user may become progressively less satisfied with
the rest of their life, due to the contrast between reality and the feelings of euphoria. When not
experiencing the immediate effects of euphoria, the addict may feel increasingly confused, anxious
and restless. They may also experience paranoia. These psychological symptoms can only be
alleviated by the user taking more heroin. As these negative withdrawal symptoms then disappear, it
reinforces the individual to continue to use heroin.

Physical effects
The user will also feel their skin become warm, experience a dry mouth and their limbs may feel
heavy. There is often a feeling of nausea or actual vomiting. As the amount of heroin builds up,
th ey will experience nausea and vomiting on a less frequent basis, as it depresses the part of the
brain associated with this action. A person's heart rate and breathing will slow down. often to life-
threa tening levels. This is because it changes the activity of neurochemicals in the brain stem, which
is where automatic functions. incl uding breathing and heart rate, are controlled. Mental fu nctioning
will become less clear and they will feel drowsy for a number of hours once the initial euphoria has
faded. A long-term user is likely to experience lung problems because of the continual depression
of the respiratory system. Depending on how the person consumes the drug, they may damage the
nasal ti ssues (if snorted) or may get abscesses and collapsed veins if they inject heroin.

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Mode of action
Heroin attaches to receptors that would typically receive input from endorphins. During everyday
activity, a moderate amount of endorphins is naturally produced, causing the release of dopamine
and facilitating the reward systems within the brain. If the body is put under stress and pain,
~ Key terms
Endorphins: a group of
•
hormones in the brain that
receptors are stimulated and the level of endorphins is increased. These lock onto the receptor sites bind to opioid receptors.
that transmit information about pain, blocking the brain's ability to register pain. They are involved in pain
Heroin acts like a massive release of endorphin into the brain. Once heroin has been taken, it quickly reception and emotions.
hydrolyses into morphine. which binds to opioid receptors concentrated in the reward pathway Cortex: the outer layer of
(ventral tegmental area. nucleus accumbens and cortex) and pain pathway (thalamus, brain stem the brain, consists of grey
and spinal cord) of the brain. This morphine is an opiate that attaches to the opioid receptors on the matter and involved in
post-synaptic membrane. When these opioid receptors in the brain become activated by the opiate, higher mental functioning.
they inhibit the activation of GABA, a chemical known to inhibit the release of dopamine. Once GABA
Thalamus: part of the
is inhibited, dopamine can flood the synaptic gap, which leads to sustained activation of the post-
brain associated with
synaptic membrane. This has the same effect as having lots of natura l endorphins released. In low
sensory perception and
doses of th e dru g, the release of dopamine activates the reward system and generates feelings of
consciousness.
plea sure.
Brain stem: a central trunk
of the brain located in
Exam tip the very middle, and
In an exam. il cJn be tempting to li~t all the information you know about a topic. for extends down to form
example the effect" of lwro1r1, by ~:mply ~tatu1g all the symptoms that a person may the spinal cord.
experience. It is unpor tant to read the question carefully to see 'f the quest· on is asking
for a list. or if the que<>t on want• you to show w'oer l.:rrowledge. This could include
expaini·rg why the ">ymptom·, occur, whrch will involve descr.bing the mode o' action of the
drug at ~he synapse.

Tolerance
Repeated use of heroin can create long-term chemical imbalances in the brain that are not easily
reversed. The brain adapts to the high levels of dopamine caused by the drug and down-regulates its
own natural production of it. This means that the baseline measure of dopamine is now lower than
before, so in order to get the same 'high: the user now needs more dopamine and so more of the
drug. This results in a tolerance for the drug, where the user has to increase the amount they use in
order to experience the same initial euphoria. The neural changes that have occurred due to repeated
exposure to heroin mean that these areas of the brain will only function normally in the presence of
the drug, which creates dependency.

Withdrawal
Withdrawal may occur within a few hours of taking heroin. How quickly withdrawal symptoms are
experienced directly relates to the level of use; the more a person uses, the quicker and more intense
the withdrawal symptoms will be. A person may become agitated if they are unable to take any
heroin when experiencing withdrawal symptoms. Withdrawal can be very painful and may include
symptoms such as muscle and bone pain, insomnia, cold flashes and restlessness. Symptoms
will peak 24-48 hours after the last dose of heroin, and can last up to a week. The symptoms will
gradually subside as the level of drug in the body reduces.

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Nicotine
Nicotine is a nitrogen-containing chemical, made from plants, mainly the tobacco plant. It can also be
produced synthetically. Nicotine is included in cigarettes, which are then smoked. It can also be used
as an insecticide, so is not just for human consumption.

Psychological effects
Nicotine makes the smoker feel very relaxed as soon as they inhale the drug. This makes smoking
a pleasurable experience, and stimulates the reward system, making the smoker want to continue
smoking. The reduction in stress experienced when smoking creates a psychological dependency.
This is in part due to the fact that nicotine deprivation can be stressful in itself, and is relieved as
soon as the person smokes again.

Physical effects
Nicotine is highly addictive. The effect of nicotine on the body is almost instant, as it quickly enters
the brain's blood supply. Drug levels peak within 7-10 seconds of inhalation, creating a sense of
relaxation. The acute effects of nicotine reduce within a few minutes, causing the need to continue
repeated intake throughout the day. As the dopamine reward system is stimulated. smoking creates
a positive feeling in the smoker. This happens with each inhalation of smoke, so is continually
reward ing, which is why people become psychologically dependent on cigarettes. The alertness
experienced by smoking quickly subsides and concentration can slow down. This creates th e feeling
that the person needs the nicotine in order to function, because the body has adapted to having
nicotine present.

Smoking increases the levels of carbon monoxide (CO) in the blood, resulting in less oxygen being
available. Less blood flows to the surface of the skin and can give the appearance of cool and clammy
skin, while also making smokers look grey in the face due to the more limited blood flow. Long-term
nicotine use can result in an irregular heartbeat and skin may age prematurely, making a smoker look
older than they actually are. The presence of nicotine in conjunction with the additional chemicals in
cigarettes contributes to lung disorders or cancers. It can also lead to insulin resistance, increasing
the likelihood of diabetes.

Mode of action
Nicotine enters the blood
stream and binds to the Nicotine stimulates acetylcholine (ACh) synapses as nicotine molecules are the same shape
acetylcholine receptors. as acetylcholine. Acetylcholine helps synapses to modify and change, which makes synaptic
This causes the neuron
to fire more frequently. transmission easier. It also stimulates the dopamine reward system. The ACh synapses are associated
with thinking and learning, with greater stimulation increasing alertness.
Presynaptic
cleft As Figure 8.1 shows, nicotine binds to the ACh receptors, causing the neuron to fire more frequently
due to nicotine stimulation. This reaction explains why smokers often report greater feelings of
alertness or quicker reac tion times. Nicotine indirectly increases the neural transmission of several
neurotransmitters, dopamine being one of them in the reward pathway of the brain, generating
positive feelings that ac t as a reinforcer for continued smoking. as with other drugs such as heroin.
Nicotine may also exert a sedative effect, depending on the level of the smoker's nervous system
arousal and the dose of nicotine taken.
Postsynaptic
cleft Immedia tely after exposure to nicotine, the sympathetic nervous system is activa ted and the adrenal
glands release epinephrine (adrenaline) into the bloodstream. The rush of adrenalin causes a sudden
• Nicotine release of glucose as well as an increase in blood pressure, heart rate and respiration. The glucose
• Acetylcholine receptors production raises blood sugar levels and will inhibit appetite. Nicotine also suppresses insulin output
from the pancreas, causing smokers to be slightly hyperglycemic, which is when there is too much
Figure 8.1 01agram to show the sugar in the blood. This can make smokers feel increasingly thirsty.
effect of nicotine on the synapses

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WIDER ISSUES AND DEBATES

Psychology as a science
The development of technology has made a fundamental difference to our understanding of the
effects of substances. It is now possible to use brain -scanning techniques to see the functioning
of the brain as it occurs. This helps to further the development of health psychology as a field of
science.

This understanding can help to influence the development of treatments that are more effective.
as they directly address the physical symptoms experienced when withdrawing from a substance.

Tolerance
Nicotine is metabolised fairly quickly in the body, disappearing from the body in a few hours.
Therefore some tolerance is lost overnight, when the smoker is not inhaling nicotine, and smokers
often report that the first cigarettes of the day are the strongest as their tolerance is at its lowest.
Tolerance progresses as the day develops. and later cigarettes have less effect.

The symptoms of withdrawa l. rather than the effect of the drug itself create a tolerance cycle as the
person smokes more frequently to avoid the negative symptoms of withdrawa l. While nicotine is
extremely addictive. not all smokers will feel the need to increase their intake, with some maintaining
a low level of nicotine use for many years. while others quickly increase.

Withdrawal
Withdrawal symptoms may begin within a few hours after the last cigarette and include irritability,
sleep disturbances. headaches. difficulties in concentrating and increased appetite. Symptoms
generally peak within the first few days and may subside within a few weeks, although for some
people they may persist for months or longer. Craving nicotine is considered a major obstacle to
overcome when stopping smoking. Experiencing an urge to have nicotine can last for up to six
months, and for some the pleasure of smoking makes it a constant battle not to reach for a cigarette.

In addition to the physiological symptoms, withdrawal can create a number of psychological

difficulties. It can be difficult for some people to overcome the problem of no longer engaging in
the behaviour of lighting a cigarette and smoking it, as these behaviours are associated with the
pleasurable effects of smoking. Smokers often associate having a cigarette with having a good time.
which makes the behaviour reinforcing and difficult to stop.

WIDER ISSUES
AND DEBATES

Ethics
The bi ologica l explanations for addiction, tolerance and drug withdrawal have largely been
conducted through animal research. This poses ethical questions about using adverse stimuli
on animals, which can be potentially fatal and likely to ca use considerable pain. It is common
practise to euthanise animals after the research data has been gathered, and this should be done
as speedily and appropriately for the species of animal used. A cost-ben efit analysis should be
conducted before such research is given ethical approval.

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Evaluation
The presence of withdrawal symptoms support the biological viewpoint that the brain relies on the
drug to function, as the symptoms indicate a deficit of the relevant neurotransmitter. It is possible
to use brain scanning and other objective assessments such as blood tests to look at the effects
of substances within the body. This provides a scientific approach to investigating the effects of
substances. As the outcome of such tests can be seen, and can be replicated due to their scientific
approach, the findings are considered reliable.

The biological explanation complements psychological learning theories. Classical conditioning

can be observed via the experiencing of pleasure after taking a drug such as heroin. The presence
of a reward system represents positive reinforcement, and the avoidance of withdrawal symptoms
by continuing to take a drug is indicative of negative reinforcement. This suggests a biological
foundation for learning theories to build on.
Many studies into the effects of drugs are undertaken on animals. For example. the Richardson
and Roberts (1996) study to look at the reinforcing effect of opiates was carried out on rats. Rats
have similar brain structures to humans but humans are influenced by social conditions, which may
in fluence substance misuse. so the find ings may not be applicable to humans. However, research
using animals that highlight significant brain structures implicated in drug misuse are likely to be
very appropria te in explaining human addiction.

The biological approach does not explain why someone first starts using a drug before the
development of any physical addiction. Social explanations may be more appropriate at this
stage. for example, peer pressure or observing others around them smoking. As a result, biological
explanations cannot be considered a full explanation of addiction as they cannot account for why
someone takes the drug in the first place. Therefore biological explanations are better suited to
explain continuation of use, tolerance, withdrawal and physical dependency.

Peer pressure 1s one reason people choose to start smoking.

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 Health psychology

Exam tip WIDER ISSUES AND

There are lots of d1ffercnt symptoms and neurotransmitters oisccssed 1n the b1olog cal DEBATES
exp anat1on for the three svbstances. You will need to know :1ese.
Nature-nurture
To help you· memory. dr.w.: a table I k.e the one t:>elow ·~which you can summanse all !.he The learning explanations
·dormabon so 1t 5 avail.1b eat a g anet!. You cou o ·~elude head·ngs such as Pos1!.1ve
seek to explain specific
effects·.. ,,.Vithora.•:.J "'ymptom·). de.
stages of drug taking
You may even .·. ant to ·1c dr· .-:or"'Yt on ;rom ater 1 ch·s co,ic. such as - reatmert behaviour, particularly
opt ons· 'or e.; h 1b .tar :r
that of the acquisition and
Mode of action Tolerance Withdrawal Effects of maintenance stages. It
physical and identifies drug addiction
psychological as a learned response: an
dependency individual continues to take
a substance as a result of
+ +
the positive consequences
r T
·- that occur from taking th e
substance and to avoid
the negative symptoms of
Learning explanations withdrawal.
All of the theories from the learning approach that you have studied in Topic 4: Learning theories, can This explana tion highlights
be used to explain why someone may start to use drugs or continue to take them. It will be helpful the nurture side of the
for you to familiarise yourself with these theories so that you can con fid ently apply them to the topic nature-nurture debate
of substance misuse. in explaining drug use.
The acquisition stage of drug use explains how an individual comes to engage in the drug-taking Individuals engage in such
behaviour, for example how they come to engage in heroin use, smoking or the drinking of alcohol. behaviour as a result of
being exposed to it from
This occurs through the development of an association between the drug and the positive feeling that
others. They then continue
occurs as a result of taking the substance, which may include feelings of relaxation. This is a form of
to participate in such
classical conditioning. Social learning theory can also explain the acquisition stage. Individuals start
behaviour as a result of
to smoke, drink alcohol or take heroin as a result of observing those around them engaging in such
the positive consequences
behaviours and witnessing them having a positive effect from it. This acts as vicarious reinforcement.
experienced from either
The maintenance stage of substance use is best explained by operant conditioning. Having a positive taking the drug or the
experience from taking a substance. for example having a buzz from heroin or feeling a sense of well- negative consequences of
being after drinking alcohol, acts as a powerful reinforcer that makes the behaviour more likely to be withdrawing from it.
repeated in the future. The punishment of withdrawal symptoms should the individual stop taking
the drug will also act to maintain future repetition.

Operant conditioning
Central to the learning approach is the concept of rein forcement. Positive reinforcement explains
the early stages of someone continuing to take a substance after th ey have tried it. It explains why
individuals continue to take heroin, nicotine and alcohol.

The drugs initially create positive feelings in the person. Alcohol and heroin have relaxing benefits
and can induce a sense of well-being. Heroin may also remove any feelings of pain. All of these
effects can be reinforcing to the individual. They make the individual want to take the drug again in
order to recreate the same effect. They learn to associate the drug with the positive feelings they
experience after taking the drug.

Continued smoking can be explained by operant conditioning, despite the initial reaction to
nicotine often being feelings of nausea and light-headedness, which are not in themselves

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reinforcing. Smoking can reduce anxiety and increase concentration. These positive feelings are soon
experienced after trying a cigarette and, therefore, quickly become reinforcing to the individual
Feelings of nausea subside, and are often only experienced during smoking the initial cigarettes.

Positive reinforcement is not always due to the consumption of the drug. Drugs. such as alcohol and
nicotine, are often taken socially and reinforced by the approval of friends or peers, so continuing to
drink or smoke can also be reinforced by praise from those important to us.

Operant conditioning helps to explain the maintenance of drug use. For example. the symptoms of
withdrawal from heroin can be unpleasant. Heroin users, therefore, continue to use the drug to avoid
the negative symptoms of withdrawal. This is an example of negative reinforcement where the drug-
taking behaviour is undertaken to avoid a negative consequence (withdrawal).

WIDER ISSUES
Social learning theory
AND DEBATES According to social learning theory, our observations of other people engaging in addictive behaviour
can lead to the development of addiction. When we observe the behaviour and reactions of other
The use of psychological people using drugs, we may wish to repeat what we saw. particularly if the person is considered a
knowledge in society role model or is looked up to by the individual. It may be that the individual observes the positive
Social learning theory has experience in th e other person when they use the drugs. and they therefore want to experience a
informed health campaigns
similar reaction and so they use the drug.
to discourage young people
from smoking, and also to This explanation explains smoking behaviour and alcohol use, both of which can be considered social
inform parents and other behaviours; the drug-taking behaviour can form part of the group's culture and is. therefore, read ily
adults about children engaged in within social settings. For example, students leaving home and attending university make
copying adult role models. friends with other studen ts in the first few weeks at university. This is likely to occur within a social
One such campaign showed setting such as in a bar or pub. Students see others drinking large amounts of alcohol or engaging in
a range of adults displaying drinking-related activities. They may choose to copy such behaviour because it looks like the other
negative behaviours. such as people are having fun while drinking. and because they want to be liked by those people.
smoking and vomiting from
Social learning theory is particularly suited as an explanation for nicotine use. particularly as initial
alcohol, and in each scene a
attempts at smoking may result in nausea and, therefore, are not initially reinforcing. For example, a
child copied the behaviour.
person may look up to an elder sibling. If their sibling is observed smoking. the younger person may
It has also informed the
want to copy this behaviour due to their sibling being a role model.
regulation of tobacco sales;
today tobacco products are
screened from view in shops
Developmental psychology ~
Adolescence is a critical period in the development of smoking, and is. therefore. of concern to
and supermarkets to prevent
developmental psychologists. Peer modelling and pressure to initiate smoking behaviour is a
children being exposed to
key factor in the development of smoking and its continued use into adulthood. Friedman et al.
product branding.
(1985) used a structured interview on 157 teenagers to investigate smoking initiation. They found
that peer encouragement and exposure to smoking peers were significant ri sk factors associated
with onset and continued smoking behaviour. Urberg et al. (1990) surveyed 233<4 adolescents and
found that both peer influence and modelling accounted equally for smoking behaviour, but in
particular th at smoking was not directly affected by peer encouragement to smoke, but rather
through lack of discouragement.
Jackson (1997) examined initiation and experimentation stages of alcohol and tobacco use in
a sample of 1272 teenagers. and found modelling of peers and perceived drug misuse in the
population were strongly associated with initiation and experimental use of the drugs.
As the path from initiation and experimental stages of drug misuse in teenage yea rs through
to adulthood is strong. developmental research into drug misuse has important applications
in identifying at risk groups and developing health strategies and regulations to prevent drug
misuse early on.
----------------------------
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Raising the age limit to purchase nicotine and alcohol helps towards preventing teenagers being able
to access these drugs, so limiting the availability within the population and, therefore, their exposure. In
Taking it further I'
order for this theory to explain substance use, the person has to observe an individual undertaking the
Consider the television
behaviour. This can occur in person. for example among friends, or can be via the media.
programmes currently
Many television programmes include pub scenes, for example, where everyone is shown to be having shown. How many of
a positive and enjoyable time while drinking. This can be appealing to others who choose to copy this these programmes have a
behaviour in order to have the same experience. 'local pub' where central
characters visit regularly?
Individuals exposed to very different cultures may have different experiences of observational
What experiences do the
learning. For example, khat is an agonist drug, typically smoked and derived from a plant most
television programmes
commonly grown in the African continent. Growing up in an environment in which khat is an
depict in the pubs?
important part of decision making, a person may be more inclined to copy such behaviour than
Think about whether this
someone who does not see it as part of their cultu ral background.
behaviour would make it
Social learning theory is less effective as an explanation of heroin use. Individ uals may experiment more likely that a viewer
with heroin because they see their favourite television character doing so but are less likely to be may be encouraged to
exposed to peers engaging in such behaviour, unless they are submerged in a drug-taking subculture. engage in similar behaviour.
However, heroin is not a drug that is particularly glamourised by the media; in fact it is often
Do you th ink the ban on
portrayed with nega tive consequences for the user.
cigarette adverti sing,
particularly in promoting
Classical conditio ning
sporting events, can help
Classical conditioning ca n be helpful to explain the development of addiction an d tolerance to
prevent some people taking
some drugs. The central premise of classical conditioning is based on that of a system of learned
up smoking?
association. Behaviour is repea ted as a result of developing an association between a specific
behaviour. such as taking heroin and the association with the pleasurable feeling for engaging in the
behaviour. such as feelings of euphoria. An association between heroin and euphoria is established
quickly, explaining why it has such addictive properties. Alcohol can also be explained by a learned
WIDER ISSUES
association between drinking and its inhibitory and sedative qualities. However, classical conditioning AND DEBATES
does not lend itself to explaining the acquisition of smoking behaviour because the first cigarette
smoked is often considered to be an unpleasant experience. The use of psychological
knowledge in society
An individual can also develop an association between environmental cues and the behaviour, which
The principles of classical
makes it more likely they will engage in taking the drug in specific situations. For example, a person
conditioning can be applied
may associate eating a meal with having a drink. The meal would, therefore, be seen as a conditioned
both to treat drug misuse
stimulus and the individual will experience cravings for a drink with a meal. Identifying these
and to explain it. Aversion
environmental cues can help an individual in treating an addiction, as they may seek to address, therapy involves associating
and, therefore, reduce the association between the environment and drug by engaging in alternative the drug with an unpleasant
behaviours when in such environments. stimuli. A recen t meta-
One form of learning that occurs as a result of classica l conditioning is drug tolerance. Drug-taking analysis of the effectiveness
behaviour (such as using a needle or even opening a bottle of beer) functions as a conditioned of aversive smoking
stimulus that predicts the introduction of the drug into the body. Eventually the act of drug taking strategies (including rapid
triggers an anticipatory response: the secretion of drug antagonists that help eliminate the drug smoking) did not find
from the body. The ability of experienced drinkers to consume a lot of alcohol withou t showing much significan t evidence that
effect is a sign th at the body is adapting to the drug. Classical conditioning has occurred. Alcohol aversion therapies worked to
consumption then triggers a strong anti-drug action that reduces the effect of the drug. As a person help individuals quit in the
becomes addicted, the drug has less and less effect, and the person is considered to have developed long-term (Hajek and Stead,
2011).
a tolerance to the drug.
Classical conditioning explains the use of heroin as well as the consumption of alcohol. The initial
aversive reaction of nicotine. however, does not create an association between a cigarette and a positive
reward. As a result, nicotine use is less likely to be explained via the classical conditioning approach.
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I • A "' - ~- • I '
r Tolerance and classical conditioning ~
Siegel et at. (1982) wanted to understand why some addicts died after taking a dose of the drug that
they had taken many times before. He tested this by giving rats injections of heroin every other day
for 30 days and gradually increasing the dose to develop a tolerance of the heroin in the rats.
The rats were placed into two experimental groups and a control group.
Group 1: These rats received their heroin injections in Room 1. which was the room that housed
all the rats. They received their sugar injections in Room 2, which was a room that differed from
Room 1 in two ways: no rats were housed there and a machine generated constant 'white noise'.
Group 2: These rats received their heroin injections in Room 2, and their sugar injections in Room 1.
Control group: These rats received injections of the sugar solution in both Room 1 and Room 2
on the same schedule as the other rats.
At the end of the 30 days. rats in all three groups were given a very large dose of heroin.
Almost alithe rats in the control group died after being injec ted with the large dose of heroin
because they had no tolerance fo r its lethal effects. Almost 64 per cen t of th e rats in Groups 1 and
2 who received the injection in a differen t room from th at in wh ich they were given their regular
dose of heroin died. Almost 32 per cent of the rats given the heroin in the same room as they
were usually given it died.
Siegel et at. concluded that the environmental stimuli in which drug addicts usually take the drug
serve as a conditioned stim ulus that produces a conditioned response that increases tolerance for
the drug's effects; a conditioned response consisting of biological changes that counteracted the
effects of the drug they were about to receive. They sta ted that when the rats received the final
injection in a different room, the conditioned response didn't occur, which increased their chances
of dying from the overdose.
- - - -- -- - - - -
Evaluation
Social learning theory explains why someone might start using drugs because of external influences
such as peers, family or the media. This was found in the study of Ennen. Bauman and Koch (1994)
where spending time with friends who either smoke or do not smoke makes it more likely individuals
will also act the same way (although non-smoking friendship groups were more likely to establish
anti-smoking norms). The explanation of external influences is not considered within the biological
approach. Within the learning approach external influences provide an explanation for the 'nurture'
side of the nature-nurture debate. This explanation, however, fails to explain why not everyone gives
in to influence from peers and why some individuals engage in behaviour despite not being in a
social setting where that behaviour is approved of.
Social learning theory highlights how family members may ac t as role models that can help to
explain trends in alcohol use in fa milies. However, fami lies also share genes, and this may be a
contributory factor. It is, therefore, not possible to clearly determine wheth er the in fluence in alcohol
use is social or genetic.
Many drugs are known to create a response that is rewarding to the individual and can. therefore,
positively reinforce their behaviour. Operant conditioning provides an explanation as to why
individuals carry on taking drugs after a positive experience. Not every inciden t of drug taking,
however. is positive.
Operant conditioning fails to explain why someone would continue to take drugs after a negative
experience, for example after a bad hangover or after feeling ill following heroin ingestion. This
explanation fails to take into account addiction, which can also explain why individuals take
substances even after a negative experience.
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 Health psychology

Classical conditioning cannot explain why people start smoking, because most people report that the
taste of their first cigarette was unpleasant. This should put people off but it does not, suggesting
that there are additional influences other than positive reinforcement in the acquisition of an
addiction to nicotine. However, it is a very good explanation for the acquisition of a heroin addiction
because the first use of heroin creates feelings of pleasure.

Individual differences
There are other explanations that seek to explain why some individuals may be more likely to engage
in substance-taking behaviour. These individual differences are not present in everyone, and can help
to explain individual variation in drug-taking behaviour.

Personality characteri stics

Sensation-seeking personality
Some individuals have a preference for engaging in risk-taking experiences. It is a personality trait
and they will readily engage in sensation-seeking behaviour that creates a strong personal response.
This can include undertaking extreme sports but can also contribute to drug-taking behaviour
as another risky activity. Zuckerman (1979) originally identified this trait in individuals. He initially
wa nted to look at the reasons behind why adolescents took risks in relation to friends and sports. His
study found a high correlation with this personality trait among drug users.

This personality type can help to explain why individuals begin to use drugs, as they search for new
experiences, but does not necessarily explain why they continue to do so, as the experience no longer
has the same risk sensations for them. The continued behaviour is likely to be due to other factors
such as biological or learning explanations. As this sensation-seeking tendency is part of an individual's
personality, it is not something that can easily be changed. Instead, they will be encouraged to manage
their sensation-seeking feelings or channel them into other, less harmful, activities.

Personality disorder
There is a correlation between the presence of various personality disorders and drug or alcohol
addiction. What is not fully clear is whether the presence of a personality disorder makes a person
more vulnerable to substance use, or if the substance use contributes to the development of later
personality disorders. Irrespective of the difficulties in identifying whether one contributes to the
presence of the other, the presence of personality disorder and a substance use problem results in
these disorders being described as co-morbid conditions. They are both present and both create
difficulties for the individual.

Extraversion
Extraverted personalities are often associa ted with alcohol consumption and smoking, though
smoking to a lesser extent. Martsh and Miller (1997) looked at extraversion as a predictor of alcohol
use, and of binge drinking. They suggest regular drinkers are more extravert than light or non-
drinkers, but alcoholics are more introverted than social drinkers.

Exam tip
When cornpanng expiJn,1t1on~. it ~~ be~t done in a methodical way rather than simply
describing one explanJL10n .1nd then the other. Cons·aer for every po' nt you are rnJk1ng
how the two expiJnJt•on~ ;Jrc ~imilar or d1fferent. For example, 'The biological and lear·1 ng
exp anations both prov1de expl.:wation~ of addictiOn, however. the biological approac>1
says ... which s d 'ferer•t frorn the lea•n1nq approach. which a•gues .. .'

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How do we treat drug addiction?
When considering how to treat addiction, it is important to consider all of the explana tions for
addiction previously discussed in this topic. Treatment methods will differ depending on the
approach. For example, aversion therapy is suggested to treat addiction from a learning perspective.

Treatment options include:

• drug replacement programmes, such as methadone

• behavioural programmes, such as aversion therapy

• cognitive programmes, such as hypnotherapy.

Treatment for heroin

Methadone treatment programme
Drug-replacement programmes provide individuals who are taking illegal drugs, such as heroin,
with an alternative drug that is controlled by a medical professional. The aim of this is to support
th e person, over time, to reduce the amount of drugs they use while also ensuring that they will not
experience any serious side effects from taking some of the illegal drug that has been contaminated
in some way. Drug-replacement programmes for heroin often include the practice of taking the
replacement drug orally, in liquid form, rather than injected into the body, as this is much sa fer for

~ Key terms
Synthetic opiate: a drug
that mimics an opiate
• th e drug user. A freq uently used drug-replacement programme is tha t of prescribing heroin users
with a drug ca lied methadone.

Methadone is a synthetic opiate. It replaces heroin at the synapse, wh ich allows the drug user to
function normally. Providing the individual with methadone as a replacement means the person
(heroin). avoids experiencing the withdrawal symptoms that result from not having heroin in their body.
Detoxification: a treatment Methadone stays in the body longer than heroin would do, and only requires a once-a-day dose.
for addiction to drugs or Methadone reduces the effects of heroin withdrawal, but does not lead to the same 'high' associated
alcohol intended to remove with heroin use.
the physiological effects of The dose given to the person is decided for each individual by a medical professional. As methadone
the addictive substances. can be harmful if too much is given at once, a doctor will start off at a low dose when the person is
A person is helped to first prescribed methadone. Over the next few weeks, the dose may be increased so that it has a
overcome the physical and therapeutic effect. A person will need to have their use of the drugs supervised in a pharmacy until
psychological dependence
it has been decided that they can be trusted to have small amounts of methadone kept in a secure
on a substance.
place at home.

Methadone is used as part of a maintenance programme, so ex-heroin users will often continue
to take methadone for a long time. However, some people can reduce their methadone dose and
eventually come off methadone for good. Once a person has been stabilised on methadone, the
process of detoxificati on can start. The amount of methadone is reduced slowly. There will still be
withdrawa l symptoms when coming off methadone, and doing this slowly can minimise or reduce
almost entirely any negative symptoms withdrawal may bring. At th e end of the detoxification
process, the person will not feel that they need to have methadone and, most importantly, will not
consider themselves to need to take heroin in order to function.

Evaluation
This approach can take many months to achieve a full reduction and detoxification as the reduction
in substance use is very gradual. It therefore requires the person to continue to engage with
the programme for quite a long period of time. If an individual chooses not to carry on with the

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 Health psychology

treatment, it makes it likely that they will return to drugs as they will still have feeli ngs of dependency
and addiction. Similarly, because the treatment is gradual, it will only work if the person is committed
to a long-term programme. It is not helpful for those who want to stop taking all drugs straightaway.

It can help to address some of the social influences of drugs, including red ucing the need for a
person to approach a drug dealer. This can reduce their exposure to other drugs. If a person is not
spending time with other people who share drug-taking attitudes, this can have a positive effect on
external influences. On this basis, drug-replacement programmes address the nurture explanations
of drug use, such as those considered by social learning theory.

The treatment programme is carefully controlled and overseen by medical professionals. This is much
safer, and more successful, than a person simply stopping taking heroin. As there can be unpleasant
side effects when withdrawing from substances, the person is more supported by undertaking
treatment in a controlled way. Hedrich et al. (2012) found that starting a methadone programme for
offenders in prison and continuing the support into the community has a positive effect on success
rates, with more offenders remaining drug-free when ou t in the community.

Methadone, and other oral medication, avoids any dangers of contracting blood-borne viruses, such
as hepatitis or HIV, due to sharing needles with other drug users. It can also prevent other health
complications through using needles when taking drugs, such as blood clots. This can provide an ~ Taking it further fl
additional, short-term health benefit while reducing substance use.
The giving of methadone
While drug-replacement programmes typically relate to heroin use, they can be applied to other prescrip tions for the user
substances. It could be argued that the increasing use of electronic cigarettes for smokers, which to keep them in their home
reportedly contain fewer harmful chemica ls, are an alternative to nicotine and, therefore, a form of has resulted in media
drug-replacement treatment, albeit unlicensed. The treatment effectiveness of thi s emerging market attention in recen t years,
remains to be seen. often due to young children
Drug-replacement programmes do not address the reasons why the person started using heroin getting hold of the drug
in the first place. This can leave people vulnerable to start using drugs again, if the reason for their and drinking it themselves,
initial use is not also addressed in addition to the physical addiction. Hasan et al. (2014) found that or the user selling the drug
combining drug-replacement programmes with psychosocial support increases the likelihood that to other drug users.

a person will not return to drug use. It can be argued that the psychological treatment allows the If you were a health
person to address the underlying motivation for their drug use. practitioner, what could you
do to minimise this from
There have been documented cases where young children have accidentally drunk methadone that
happening and to make
was not correctly locked away in the family home. These cases show there may be risks associated
sure the person was going
with allowing a person to self-administer methadone without going to a pharmacist. Such decisions
to use it themselves?
are, however, made by professionals aher a full investigation about the safety of others.

Detoxification programme
A detoxification programme aims to reduce the level of heroin in the body in a controlled manner.
Detoxification programmes provide supervised withdrawal from a drug of dependence so that th e
severity of withdrawal symptoms and serio us medical complications are reduced to a minimum. It
usually involves supervision in the period immediately aher the person stops taking the heroin, when
the typical 'rebound' symptoms of drug withdrawal are at their most severe.

During a detoxifica tion programme, the emphasis is on the physical effects of heroin addiction. The
aim is to reduce the level of heroin in the body, so that the body can return to normal functioning,
without the influence of heroin on the synapses. It is a somewhat simple way of treating heroin
addiction in that the individual is observed and monitored while experiencing withdrawal from
heroin.

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 Health psychology
I • A "' - ~- • I '
There is likely to be a clinician to provide support to the individual within an in-patient facility, but
this support is not a structured therapeutic approach during the acute withdrawal phase. Some
detoxification programmes offer additional treatments such as cognitive behavioural therapy (CBT)
to address the individual's beliefs and attitudes around their substance use. It is also possible that
holistic treatments, such as acupuncture, are offered, which aim to reduce some of the physical

~ Key term
discomfort experienced during a detoxification.
Heroin withdrawal is rarely life-threatening. but it has unpleasant side effects. For heroin users,
Abstain: stop yourself from detoxification is a form of palliative care for those who wish to abstain. It also provides a period
using a substance. of respite from drug use, and can act as a precursor to more specific forms of drug-free treatment
for drug dependence. The unpleasant feelings of the withdrawal can act as an aversive stimulus for
heroin users, which can then act as a barrier to them engaging in a detoxification in the absence of a
substitute such as methadone.

Evaluation
Detoxification is a process that aims to achieve a safe and humane withdrawal from a drug of
dependence. It does not address the reasons why the person started taking the drug initially, nor
does it provide the individual with any strategies or support to address any futu re temptation to
use heroin again. As a result, the potential for relapse rema ins high. As it only addresses the physical
addiction to the drug, it can be considered an overly simplistic way of addressing heroin use.

Detoxification is often conducted in conjunction with heroin replacement programmes. such as the
use of methadone. To undertake detoxification, (even in a controlled manner), in the absence of a
replacement substance can be distressing and uncomfortable for the individual. This makes it less
likely that an individual will want to engage in a detoxification-only programme.

The detoxification process can start as soon as an individual stops taking heroin. While it is
unpleasant, after a week without taking the drug the worst of the withdrawal symptoms have passed.
This therefore provides a quick way to reduce the levels of heroin in the body, whereas methadone
programmes can take many weeks before an individual is no longer taking any substance.

Supervised heroin detoxification often takes place in an in-patient setting. which is more effective
than if someone undertakes it as an out-patient (Mattick and Hall, 1996). This creates a resource
demand where there are often waiting lists for individuals accessing such facilities due to the cost
and resources required to provide such a service. As a result, an individual may have a period of time
to wait before they can access a detoxification programme. During this waiting time, they remain
vulnerable to continued heroin use, potential harm as a result of their use and the likelihood that
they could change their mind about accessing the treatment.

Treatment for alcohol

Aversion therapy
Another approach to cha nge substance behaviour is to directly address the behaviour itself. The
behavioural approach advocates that new behaviour can be 'learned' in order to overcome addictions
and, therefore, replace the addictive behaviours. Aversion therapy is one such behavioural trea tment,
and is based on learning theory. One of the basic principles of learning theories is that all behaviour
is learned and, on that basis, undesirable behaviours can be unlearned under the right circumstances.
It is based directly on the classical conditioning approach of learning theory. The goal of aversion
therapy is to decrease or eliminate undesirable behaviours.

Aversion therapy is an application of the branch of learning theory called classical conditioning.
Within this model of learning, an undesirable behaviour, such as smoking or drinking alcohol, is
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 Health psychology

matched with an unpleasant (aversive) stimulus. The unpleasant feelings or sensations become
associated with the behaviour, and the behaviour will decrease in frequency or stop altogether. It has
been applied to a number of addictions, including smoking.

Typically when someone drinks alcohol. the body metabolises the alcohol by turning it into a
substance called acetaldehyde. This is a toxic compound that can cause the unpleasant symptoms
associated with excess alcohol consumption such as vertigo, weakness, headache, anxiety and
possibly even chest pain. Acetaldehyde is usually broken down quickly in the body and made into
acetic acid, which is harmless.

Aversion therapy is most commonly applied to ensure alcoholics do not drink akohol.

An individual undergoing aversion therapy for alcohol use is given a drug called disulfiram shortly
before drinking alcohol. This drug, often in tablet form, works by interfering with the ability of
the body to metabolise alcohol, that is it interferes with the mechanism that breaks down the
acetaldehyde. The chemical can then build up in the body to produce unpleasant symptoms. The
fea r of developing these symptoms can be enough to deter the individual from drinking while on the
drug. Those who do consume alcohol while on the drug will develop an aversion due to the pairing of
the alcohol with the unpleasant symptoms. Individuals become classically conditioned to associate
the taste, and even th e smell, of alcohol with the negative symptoms. They then choose not to drink
alcohol to avoid the negative symptoms.

While disulfiram has been in use for many years, there have been recent advances in similar. but
more developed, medications to use within aversion therapy. Medication that works in the same
way of developing aversive symptoms but also rewards abstinence with positive feel ings has had
encouraging results. This medication, tryptophan, is known to increase levels of the neurotransmitter
serotonin, which is associated with feelings of optimism, tranquillity and general well-being.
Therefore, people who take this drug will not only abstain from alcohol. but will feel more positive
while doing so, which acts as a positive reinforcement for abstaining.
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 Health psychology
I • A "' - ~- • I '
Evaluation
Aversion therapy differs from those types of therapies that adopt principles of operant conditioning.
Therapy that uses an operant conditioning approach would present the aversive stimulus, usually
called punishment, after the behaviour rather than together with it. In presenting the aversive
stimulus at the same time as the unwanted behaviour, it has a greater treatment effect based on the
principles of classical conditioning. Ethical concerns have, however, been raised about deliberately
making people experience unpleasant symptoms, even if they do give consent to the treatment.
The person is not required to have any insight into why they engage in the behaviour, which is often
the case for more cognitive treatments such as CBT. However, it could be argued that if a person
does not understand their motives for drinking, this could make them vulnerable to returning to the
substance again in the future.
Aversion therapy can be very effective in the short term as the unpleasant side effects are
immediate, therefore creating an immediate behaviour change. However, relapse rates are high with
this therapy. The individual is also still likely to have cravings as these are not addressed by taking the
medica tion. It is usual for aversion therapy to be combined with other forms of trea tment to address
th e motivation for the behaviour. Without other forms of treatmen t in addition to the aversion
therapy, the person may simply replace the old undesirable behaviour with a new undesirable one.
There can be potentially serious side effects through taking toxins to suppor t behaviour cha nge.
Side effects can include liver or nerve damage. Those with existing medical conditions may be more
prone to experience these side effects. This could reduce access to this treatment for individuals with
existing medical conditions that could be made worse by the side effects of the aversive medication.
This treatment can only be used for people who want to abstain completely from alcohoL It is not an
appropriate treatment for those who want to reduce their drinking to within safe limits. Behavioural
change is needed instead for such individuals. Learning explanations would be interested in exploring
what makes them drink excessively, such as peer influence, the environment they drink in, etc.

Cognitive behavioural therapy (CBT}

CBT is a talking therapy that uses a problem-solving approach to alcohol dependence. It aims
to identify unhelpful and unrealistic thoughts and beliefs that may be contributing towards an
individual's alcohol dependence. These can include reasons why a person chooses to drink, which
may include as a way of relaxing or to cope with problems. Once an individual has identified the
thoughts and beliefs that keep them drinking, the individual is encouraged to change their thoughts
to be more helpfuL For example, an individual may believe that they are unable to relax without
drinking. CBT may help the individual to instead believe that they have other ways they can relax,
besides alcohoL They will then be encouraged to engage in the alternative behaviour to help them to
relax, once they have an awareness of such alternative behaviours.
CBT is also helpful for identifying triggers that may increase th e likelihood that a person will drink,
such as being in a certain environment or with certain individuals, or being in a specific mindset, such
as feeling upset. The therapist will then support the individual to develop strategies to manage these
triggers, which are known as 'high-risk situations' to minimise the potential that the individual will
feel the need to drink alcohol

Evaluation
McCarthy (2008) found that CBT was effective in reducing binge drinking but also demonstrated
an increase in the ability for individuals to refuse alcoholic drinks when in high-risk situations. This
therefore indicated that the therapy was helpful in addressing the drinking behaviour itself, as well as
the individual's coping abilities when in situations that would typically result in alcohol consumption.
514
 Health psychology

This two-fold approach increases the likelihood that an individual will be able to manage their future
alcohol consumption by providing skills that can be applied when needed as well as encouraging
behaviour change.
Many evaluations for the effectiveness of CBT for alcohol use are undertaken under the umbrella of
'substance use', which also includes drug use. It is, therefore, difficult to extrapolate the effectiveness
of this therapy approach solely for alcohol use.
For some people, spending time with a therapist discussing their alcohol use may be sufficient to
create a change in behaviour, as the individual may feel supported by the therapist and, therefore.
empowered to make a change in their behaviour. It is, therefore, possible that simply discussing their
alcohol use results in behaviour change, rather than specifically the components of the therapy itself.
In this sense, it is difficult to determine if the positive therapeutic relationship creates behaviour
change or the skills taught within the therapy.

Treatment for smoking

Aversion therapy
Aversion thera py has been proven to be effective not only in alcohol use but also with other
substances, including smoking. This treatment approach aims to pair smoking with unpleasant,
aversive stimuli that remove the rewarding feeling experienced by smokers, and replace it with an
unpleasant one, with a view to the individual no longer wanting to smoke. The process of aversion
therapy as a treatment for smoking follows the same process as with other stimulants, such as
alcohol. The only difference between aversion therapy for smoking another substance is the aversive
stimuli being used.
Aversion therapy is commonly applied to smoking through the method of rapid smoking. This
involves inhaling on a cigarette every few seconds for several minutes while concentrating on the
unpleasant feelings that arise from smoking so quickly. The participant continues the quick-puff
procedure until they begin to feel nauseated. This then serves to replace the association between
the pleasurable or comforting feelings most people get from smoking with the more repulsive
consequences of tobacco use.
Similarly, silver acetate products serve as a pharmacological aversive stimulus. They can be taken in
the form of chewing gum, lozenges and a mouth spray. When taken with cigarettes, silver acetate
produces an unpleasant metallic taste in the mout h and, therefore, has aversive qualities for smokers.

Evaluation
The effectiveness of aversive stimuli with smokers has received limited empirical evaluation to
date. As a result, it is not fully known how effective this trea tment is in order to achieve long-term
smoking cessation. Hajek and Stead (2000) found limited evidence that rapid smoking (inhaling
deeply and frequ enlly) might reduce smoking. Existing trials show little evidence for a specific effect
of silver acetate in promoting smoking cessation. The lack of effect of silver acetate may renect poor
compliance with a trea tment whose rationale is to create an unpleasant stimulus, rather than the
treatment method itself being ineffective.

Hypnotherapy
There are many psychological treatment programmes available that can be used to address addiction
behaviour. CBT is one way in which individuals can be guided to use self-talk strategies at times
of cravings to support themselves when wanting to drink alcohol or smoke a cigarette. Another
approach that has been gaining credibility as a treatment, particularly for nicotine addictions, is that
of hypnotherapy.
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I • A "' - ~- • I .
~ Key term
Suggestibility: this is a
personal quality where
• Hypnotherapy occurs when a trained therapist induces a client into a very relaxed state. This can
make them more open to suggestions put to them by the therapist, thus making them more
suggestible. The client is not put to sleep, but their focus reduces to the extent that they are no
longer aware of anything other than the words of the hypnotherapist. Their level of consciousness

the individual is inclined has been altered when placed under hypnosis before the treatment commences.
to accept and act on the In this relaxed state, ideas can be implanted into the client's unconscious that will influence the
suggestions of other person's behaviour once they are in a more conscious state. When addressing addiction behaviours,
people. They may be aware the therapist will suggest ideas such as the person no longer wants to smoke or to imagine
that they are following the unpleasant outcomes if they were to smoke again. These suggestions then form part of the client's
suggestions of others or it own thoughts, and are remembered when in a conscious state. When the person thinks about
may occur unconsciously. smoking they will then think about these thoughts, which will put them off smoking.

Evaluation
Hypnotherapy has been found to be three times more effective as a treatment in addressing
nicotine addiction than nicotine replacement therapy (Hasan et al., 2014). This support s th e
psychological influence of nicotine addiction, whereas nicotine replacement therapy focuses on the
biological sources of nicotine addiction. As such, it addresses and seeks to change the psychological
components related to continued smoking behaviour. Other trea tment methods tend to j ust focus on
~ Taking it further f'l th e physical dependency that maintains smoking behaviour.

New treatments to Hypnotherapy can be more helpful than other techniques. such as drug treatments, as it supports
address substance use are th e self-belief of the person, that they are able to make positive changes for th emselves, withou t
frequently emerging. This feeling that they need medication to help them with it. Positive treatment outcomes can often
is often in response to the be seen after just one or two treatment sessions. This makes it a very cost-effective treatment.
various new drugs that For treatments such as methadone redu ction, treatment takes a prolonged period of time before
emerge on the market and positive outcomes can be seen.
require treatment options
Some people may be put off from trying hypnotherapy as they may think that they are not going to
for their use. Research
be in control of their behaviour or that they may be vulnerable during hypnosis. As a result, they may
available treatment options
for the three substances, be more likely to try other treatment options.
alcohol. heroin and nicotine. Treatment success relies on the client being able to relax sufficiently to be hypnotised. If they cannot
Research it again as part of do this, the auto-suggestions will have no benefit on the individual. Therefore. it may not be a
your revision for the exam. treatment that will be suited to everyone. although the individual will not know if it will be effective
You may be surprised to see or not until they have tried it
how many new treatments
have emerged. It is unlikely that a person will be able to access hypnotherapy on the NHS as it is not licensed by
th e NHS for such use and, therefore, has a personal cost implication for the client. As such, this is a
A note of caution: if treatment that is not accessible to everyone.
discussing new treatments
in your exams, ensure you
Exam tip
have an understanding
When evaluatrng a treatment programme. considering how Lhey com[Jar I' wrth o thers may
of whether the treatment
be a woeful part of the eva luation. For exarnple, if there are elhrcal ·.,sues with this
options have been shown to partrcular treatment approach, are there other treatrnenb Lhat arc mort' dhical? It rs best
work. Some may be so new to expand on your cornmenc :o say why the other treatment rnJy be more ethical, to show
that no one has looked into that you understand both treatments. You can do this by sayrng 'It is more ethrcal
them in detail. because .. .'

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 Health psychology

I Motivation as a precursor for treatment

In order for treatment to be successful, a person using the drugs has to want to change their
behaviour. A common psychological model that identifies an individual's motivation, designed
specifically with drug addiction in mind, is that of the 'Stages of Change' Model (Prochaska and
~ Key terms
Rei apse: a person has
•
started to use a substance
DiClemente, 1983).1t is an influential model within psychology as a discipline, no more so than in again after a period of
relation to identifying treatment options for drug users. abstinence (not using the
The five stages of change are as follows. substance). A relapse is
not to be confused with a
Pre-contemplation: the person is not considering changing their drug use. They are unaware of 'lapse'.
the full negative consequences of their behaviour. As a result, they are unlikely to make efforts to
change their behaviour. Lapse: a one-off return to
drug-using behaviour but
Contemplation: the drug user is aware of some of the negative consequences of their drug use, which does not result in
but they are still thinking about whether changing their behaviour is what they want. They have the person fu lly returning
not yet made a definite commitment to cha nging their behaviour. to such behaviour. For
Preparation: the drug user has decided to make a positive change to their behaviour, that is, to example, a person who is
stop using drugs. They begin to plan steps towards making this change. trying to stop smoking may
have one cigarette, but
Action: the person tries out th e plans they have made to support their decision to change their
then not have any more.
behaviour. This is likely to include attending treatment programmes and developing skills to
This would be a lapse.
manage any temptation they may have to use drugs.
People who experience
Maintenance: the person has a set of new behaviours that supports them not using drugs. This both relapses and lapses
is a long-term stage and staying in this stage will prevent the person from using drugs in the will benefit from con tinued
future. support with their attempt
If a person were to return to drug use at any point (that is, have a relapse or a lapse), they will to quit.
need to make a decision about what they want to do next, and re-enter the stages of change.
The model is considered to be a cycle that a person goes through in order to manage their
Taking it further
addiction. The model is, therefore, often referred to as the 'cycle of change'. An individual's positive,
ongoing motivation to address their drug use will move through each of these stages, in the
direction shown by the arrows. Motivation may also, however, go the other way, and would suggest There are questionnaires
available on the Internet
the person is less motivated or feels less ready to make positive changes to their drug use.
that people can fill in to
look at their own motivation
to make positive change
1 in their life. Download one
Pre-contemplation
of these and think about
something that you may
want to change, such as
wanting to write more neatly
5 2 in exercise books or develop
Maintenance Contemplation a more organised approach
to learning, or something
involving an activity, such
as wanting to take up a
new hobby. Wh ile thinking
about this planned change,
4 3
Action Preparation
complete the questionnaire.
Are you ready to make that
change yet?
Figure 8.2 Prochaska and D•Ciememe's 'Stages of Change' Model
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Anti-drug campaigns
A psychologist will often work with other professionals, often with a medical or nursing background,
to develop ways to share important health messages with the general public. These messages are
known as 'campaigns', and will involve lots of advertising to encourage the general public to make
positive change to their behaviour.

Previous health-related campaigns have addressed topics such as self-assessments for breast or
testicular cancer or national programmes aimed at increasing the vaccination rates of children
following health concerns after vaccinations. From a substance perspective, campaigns have
historically included national 'stop smoking' promotions. The role of the psychologist in such
campaigns is essential to ensure the strategies underpinning the campaigns are those that will have
a positive outcome.

'Stoptober' 2014

StoP. be The campaign message is simple; if you stop smoking for 28 days in the month of October, it makes
it five times more likely that you will quit for good. There are still over 8 million smokers in England
and smoking remains the number one ca use of preventable premature death and chronic disease.
It causes a staggering 80 000 deaths and costs the NHS an estimated £2.7 billion each year. The
Figure 8.3 The logo for the
campaign title is catchy. It was designed to capitalise on a trend to give months of the year a th eme
Stoptober 'stop smoking' campaign
in the same way as 'Movember' is associa ted with an increased number of men growing facial hair in
November, in support of male cancer fundraising. It is focused on being positive and motiva tional.

The campaign was introduced in 2012 and is led by Public Health England. It is the biggest mass
quit attempt in the UK. It aims to show smokers that Stoptober understands that quitting can be a
difficult and intimidating proposition for many people, but with the right support and tools, they can
make it through the month and beyond. Stoptober report that 250 000 people in England and Wales
took part in the 2013 Stoptober challenge, and over 65 per cent made it to 28 days (160 000 people).
It is estimated that 50 000 will remain smoke free after 12 months.

It looks set to be an annual event and the 2014 campaign featured comedians to supercharge the
positive tone of Stoptober by adding humour to empathise with smokers and deliver the message.

The campaign crosses a number of advertising sources, including television, radio, road shows, online
and social media to create a sense of scale and relevance. From 8th September 2014, Stoptober
encouraged as many smokers as possible to join the challenge and prepare to quit from 1st October
by signing up online for free support tools. The tools complemented the 28-day journey and were
designed to offer support every day, this year peppered with humorous content to keep people
engaged and smiling throughout, via a physica l pack, smartphone app, text and email programs.

Stoptober launched on television with an innovative 3-minute 'sketch show' during the Emmerdale
commercial break (available to download from the Internet), fronted by comedians such as Paddy
McGuiness and AI Murray (The Pub Landlord) who delivered Stoptober's key messages in a humorous way.

The start of the advert includes pictures of individuals designed to represent the general public.
This creates an inclusive feel to it so that all smokers who see the advert are likely to feel they are
represented within those images. The pictures reflect a range of ages, ethnic backgrounds and
represent both men and women. This approach helps to draw in all smokers to the campaign and is
important for people to choose to participate.

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The comedic tone is carefully used. It purposefully avoids mention of cancer or respiratory disease.
Furthermore. the humour used is inclusive of all so as to avoid alienating a key audience. Some of the
health benefi ts of not smoking are subtly included in the advert. AI Murray hints that taste buds will
improve and his pub customers will realise how bad his beer is if they were to stop smoking. Using
humour in this way avoids people seeing the campaign as pressurising and more that they have to
stop because it improves their taste. Such direct health campaigns have been less effective in the
past as people have reported that it can feel as if they are being lectured at. This can make people
more reluctant to try to change their behaviour.

A lot of reference is made to willpower within the advert. which is needed in order for someone to
succeed in stopping smoking. At this point of the advert, AI Murray speaks a lot about how willpower
is a British trait, making reference to the war. This approach helps the viewer to identify with
historical events that required will power and aims to instil a sense of pride in the viewer. These traits
will help the person to be more resilient to the demands of quitting smoking.

While the main body of the adver t aims to highlight the benefits of not smoking. there are also links
to some of the negatives of continuing to smoke. This includes making a joke about the Cold play
song 'Yellow' being written for smokers. making reference to the tendency for smokers fingers to
become yellowed due to the nicotine in cigarettes.

In presenting the adver t as if it is a chat show, with an audience being fi lmed within the adver t, it
has a group-based approach. The viewers. while not in the actual audience are likely to feel that they
are part of the wider group. In considering making change, feeling supported by others, even if not
directly known to you, increases a sense of self-belief that the desired change can be achieved.

The 'sketch show' advert generated PR for the campaign and announced the arrival of a new,
refreshed Stoptober. Throughout September, the comedians then delivered shorter adverts
rein forcing Stoptober's key messages through television and radio to explain why smokers should act
now and sign up online to start their quit attempt on 1 October. Online and social media advertising
directed smokers to the sign up page and Stoptober's proven support tools.

Who is it aimed at?

The campaign is aimed at all smokers. As the legal age to buy cigarettes is 18, the campaign
ultimately is directed towards adults. However, the accessibility of the language used and the use of
humour is also likely to gain the attention of teenagers who have started smoking.

What psychological theories are applicable to anti-drug

campaigns?
Hovland-Yale model of persuasion
This model states that there are several factors that will affec t how likely a change of attitude is
through persuasion. For example, how likely someone will consider stopping smoking and be open
to campaigns such as Stoptober. The model states that there are three prominent factors that need
to be considered in order for a ca mpaign to be persuasive. This has led psychologists to look at
the science of persuasion to discover how to change attitudes with the ultimate goal of changing
behaviour.

1 The source (who is giving the message)

According to credibility theory, people are more likely to be persuaded when a source presents itself
as credible, for example if the person providing the message is an expert in the field.

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2 Th e message (what the message is saying)
The content of the message is an important factor. Two-sided messages, those which highlight both
sides of the argument, have a greater influence on attitudes than one-sided messages, as long as the
two-sided argument eventually gives a solid opinion. This would suggest that an effective campaign
to stop smoking needs to highlight both sides of the smoking debate, and then be clearly conclusive
about why the benefits of quitting outweigh reasons to smoke.

3 The audience
The characteristics of the audience strongly affect how likely someone is to be persuaded. Individuals
considered to be more intelligent are more likely to be persuaded by valid arguments because they
have a longer attention span and can understand the arguments better. The campaign will, therefore,
need to be structured around the audience characteristics it is aiming to persuade.

Culture can also be a contributory factor in relation to how messages are received by the audience
and, therefore, how persuasive the messages are. For example, Wang et al. (2000) found Americans
prefer products that offered 'separateness' whereas Chinese prefer products that offered
'togetherness'. This suggests different cu ltures would be more influenced by messages that back up
their opinions.

Elaboration likelihood model of persuasion (Petty and Cacioppo, 1986)

This model aims to look at attitude change by looking at persuasion, and factors that increase the
likelihood of persuasion occurring. Under this model, persuasion depends on the level of scrutiny
given to a message. The level of scrutiny falls along a continuum from close scrutiny, or 'central
processing', wh ich involves examining an argument closely, to 'peripheral processing' where short-cut
cues are used to understand a message. The level of scrutiny and processing depends on motivation.
People who are less motivated use peripheral cues that lead to 'less stable' attitude changes,
which are less likely to lead to behaviour change. People who are well motivated undertake central
processing. which is more likely to lead to sustained changes in behaviour {Crano and Prislin, 2006).

Many messages lead to both central and peripheral processing operating at once. This theory implies
that information campaigns should seek to provoke central processing of their message. A campaign
fronted by a celebrity may provoke interest and, through peripheral processing. lead the viewer
to understand the message. However, to change habitual behaviours and bring about long-lasting
change, a message has to provoke deeper thought.
Two conditions are necessary for 'effortful processing' to occur. The recipient of the message must
be both motivated and able to think carefully. A person's motivation to consider messages can be
influenced by a number of variables, including the perceived personal relevance of the message
and whether the person enjoys thinking in general. A person's ability to think carefully can also be
influenced by a number of variables, including the amount of distraction present in the persuasion
context and the number of times the message is repeated. If a person is both motivated and able to
th ink carefully about the issue and relevant information presented, it ca n generate an attitude that is
integrated into the person's overall beliefs.

Fear arou sal Oanis and Feshbach, 1953)

Fear arousal health promotions aim to inform individuals of the risks of engaging in a particular
behaviour, such as smoking. Health messages based on fear arousal may include graphic images such
as those that have been placed on cigarette packets in recent years, depicting the damage caused
to internal organs as a result of smoking. Hammond et al. {2003) found that pictorial messages on
cigarette packets were more effective in encouraging behaviour change than written warnings.

520
 Health psychology

Health commu nications. which stimulate higher levels of fear. have been shown to increase the
Taking it further
likelihood that individuals will accept the health recommendations being made within a health
campaign. It has been shown that high-fear messages produce more attitude and behaviour change
Fear campaigns have
than health communications that do not highlight hazards of the behaviour. and are, therefore, seen
been used to promote
as low-fear messages. healthy lifestyles, such
While high-fear messages have an impact on behaviour change, it is, however, necessary to use an as stopping smoking or
appropriate fear level for the campaign, as found by janis and Feshbach (1953). The individual must taking drugs. Investigate
be able to identify with the message and consider it possible to happen to them. If the fear arousal these campaigns using the
is too high for the behaviour. it increases the potential for the individual to dismiss it as unlikely Internet. paying particular
to happen to them and. therefore. does not contribute to behaviour change. The need to apply an attention to the pictures
appropriate fear level to the health message may contribute to the inconsistent results within the and messages given in the
fear arousal literature as to whether high or low fear messages are most effective. campaign.

janis and Feshbach (1953) investigated the effect of fear arousal levels within health communications
on dental hygiene. Two hundred students were separated into four grou ps of 50 participants. Each
group was allocated a fear arousal level: minimal, moderate or high arousal and a control group.
Participants were exposed to different health messages as determined by their arousal level.

The high-fear arousal group were shown pictures and descriptions of diseased mouths. including
explana ti ons about the pain of tooth decay and gum disease and awful consequences like cancer
and blindness.

• The moderate-fear arousal group were shown similar pic tures and descriptions to the high fear
arousal group, but they were much less disturbing and dramatic.

• The minimal-fear arousal group were given a lecture about teeth and cavities, but without
referring to very serious consequences and using diagrams and X-rays rather than emotive
pictures.

• The control group were given a lecture of the same length as the other conditions (15 minutes).
but this group was given a lecture on the structure and functioning of the human eye.

The outcome of the study was that the high-fear arousal message created the most worry in the
students and was rated as more interesting. This condition also showed a high level of the individuals
thinking more about the condition of their teeth than for the moderate- or minimal-fear arousal
groups. However, they concluded that while the high-fear messages did generate most concern about
dental health, the overall effectiveness of a health promotion campaign is likely to be reduced by
the use of strong fear appeal. as it produced the least change in behaviour. The Janis and Feshbach
(1953) study, therefore, showed that, after a delay between giving the message and measuring any
behaviour change. a low-fear message is more persuasive than a high-fear message.

Leventhal and Watts (1966) used low. mild and strong threat messages (on lung cancer) to influence
attitudes towards chest X-rays and stopping smoking. Their high-fear movie included close-ups from
a lung surgery operation. The three groups were compared for the number of people who took X-rays
immediately after the communications; an X-ray booth was available right outside the movie thea tre.
The results showed that the smokers in the audience did not take X-rays after exposure to the high-
threat film, though did take X-rays after the low an d moderate threat films. Reports of success in
reducing smoking were collected three months later and a greater proportion of subjects exposed to
the strong high-fear film claimed success in cutting back.

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Evaluation
One way to evaluate an anti-drug campaign is to consider the strengths and weaknesses of the
psychological theories that inform it. The Hovland-Yale model is too simplistic. The idea that
processing occurs in order. through attention. comprehension, acceptance and retention is not
necessarily the case. For example. once we start to think about the meaning of the message, we go
back and pay some or all of it more attention. so individuals are not processing in a simple stage-
by-stage manner. Furthermore. the Hovland-Yale model concentrates on external processes (the
communication, the communicator, etc) but does not take sufficient account of the underlying
internal factors associated with the viewer (for example, attention. comprehension). which is
accounted for in the elaboration likelihood model.
The elaboration likelihood model of persuasion does not result in quick attitudinal change. While
Exam tip
it is likely to result in long-standing behaviour change. it develops over a prolonged period of time
You •.vi.l be as•.ed to apply and. therefore, is less effective for rapid behaviour change. The model is somewhat oversimplified in
your Knowledge ol hea.th
considering that the two forms of processing act as separate processes. rather than on a con tinuum.
campaigns to unseen
material. Consider how you It is likely that individuals use both forms of processing. The model is not clear as to how the two
might go about expla1n:ng processes interact. It is also difficult to tell which type of processing people will use. Th is makes it
the following scena110. difficult to predict behaviour from the model.
using your knowledge of
why health ca111paigns may The elaboration likelihood model accounts for individual differences in a manner that the oth er
not be effective. John has models fail to do. It recogn ises how the same message ca n be processed differently by different
tried several limes to g:vc people using different processes. It suggests that individuals with a high need for cognition use
up smoking after see1ng ,1
th e central route, whereas individuals with low need for cognition use the peripheral route. The
health campaign that made
him consider qu1tl ng. consideration of two routes may be considered more realistic than the one route of persuasion
Every time Job~ tr e<> to outlined by the Hovland-Yale model as individuals are complex in their processing.
g've c::> ~e 'ads. oesp te
The fear arousal approach is useful for increasing health behaviours in individuals. as it demonstrates
oeing aware of the hea it''
campaigns aovert,<;ed on that fear arousal may not be the most effective way of promoting healthy living. However, this
b1 ooards and the approach does not consider other reasons, besides fear, as to why an individual may adopt a health
tele, ·s,on. behaviour. The approach suggests that graphic images on health campaigns may not be the most
effective way to encourage individuals to change harmful behaviour. Despite this, cigarettes currently
depict such images on their packets. This would suggest that the application of this approach, in
practice. is inconsistent with the findings.

Research in this area is usually conducted using self-report techniques. These are biased on the part
of the participant as they may report what they assume the researcher is looking for. As a resu lt,
the findings of research in this area may not accurately identify factors innuencing attitude and
behaviour change.

~ Taking it further ,
There are different public organisation s th at have respon sibility for developing and advert ising
health campaigns. One of these is Public Health England, though other cou ntries usually have
their own bodies for th is.
Spend some time researching some of these agencies to look at what their ongoing projects
are. They are often influenced by what is being reported in the media or by health problems.
for example alcohol campaigns came about due to an increase in antisocial behaviour by
binge drinkers.

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