ATTUD Journal Club Postings

Changing Multiple Behaviors Simultaneously vs Sequentially

In two prior blogs I described the theory and evidence that self‐control is like a muscle in that one has a limited amount of self‐control and using that up on one task can make it harder to be successful at another self‐control task (Self‐control as a Finite Resource 5/20/14). But on the other hand training one’s self in unrelated self‐control tasks can improve self‐control on a later task (Building the Self‐Control Muscle, 2/26/16).

So what does this mean for trying to change two behaviors? This is a relevant question because few smokers have smoking cessation as their only problem. Most also have problems with diet, alcohol/drug use, poor medication compliance, exercise, obesity, mental health problems, etc). So if someone has a heart attack and smokes and is obese and abuses alcohol, where should we start? The data in the first paragraph would suggest sequential is better, in part because controlling one behavior should increase ability to control another behavior at a later date.

Put another way, the question is does one attack multiple problems one at a time (sequentially) or all at once (simultaneously). This issue has been explored with many health‐related behaviors (Am Psychol 70:75, 2007). Five studies have examined this issue with smoking. The first three studies found that asking smokers trying to quit to diet during abstinence to prevent post‐cessation weight gain decreased (Am J Pub Hlth 82:799, 1992),did not change (Am J Pub Hlth 82: 1238, 1992) or improved (Jl Consul Clin Psychol 69:604, 2001) abstinence. Another study included two weight conditions, one with dieting early in abstinence and the other later in abstinence (J Consult Clin Psychol 72:785, 2004. Both dieting conditions had higher abstinence rates than a no‐dieting condition but not did not differ from each other in terms of abstinence. However, the later dieting group had less weight gain than the early dieting group. One study examined, not two, but three behaviors (Arch Intern Med 167:1152, 2007): stopping smoking, increasing activity and reducing salt intake. The simultaneous change group had slightly higher smoking quit rates than the sequential and usual care groups (20% vs 17% vs 10%). A final study intervened on five behaviors: smoking, alcohol use, vegetable consumption, fruit consumption and physical activity via an internet program (J Med Internet Research, e26, 2014) and had greater smoking abstinence in the sequential than the simultaneous condition.

In summary, the data on whether trying to changing both smoking and another behavior helps or hurts smoking abstinence rates is unclear. Usually, when I have no firm data, I let the patient decide this. So if someone wants to stop both alcohol use and smoking , that’s fine. But there are limits to this; e.g. if someone has active alcohol dependence and wants to only stop smoking, its unlikely he/she can stop smoking without doing something about his alcohol use. Also, although we often think about how behaviors go together (e.g. smoking and drinking) and thus it might be easiest to tackle both at the same time, there are other issues; e.g. experiencing both nicotine and alcohol withdrawal could be too difficult.

Thoughts – this is a tough one