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Published on January 20th, 2016 | from CAMH

Transforming Lives with the Science of Human Behaviour: Harnessing the Power of Positive Reinforcement to Encourage Smoking Cessation

By Louis Busch, Behaviour Therapist, Complex Mental Illness Program

louisbuschIn the spring of 2014 CAMH launched its tobacco-free initiative in an attempt to build an environment that supports patient recovery and promotes the safety and health of staff, clients and their loved ones.

I watched with peaked interest as the program was developed, communicated and implemented, and will be the first to admit that I had some initial reservations. Large-scale behaviour change initiatives are incredibly challenging. Heck, even small-scale behaviour change initiatives are incredibly challenging. That’s because human behaviour is extremely complex and influenced by an immense set of idiosyncratic variables.

We interact with our environments and the consequences of those interactions shape who we are, the choices we make, and the choices we will make in the future. But we come upon those interactions with a lot of baggage. Our entire history of learning, our genetics, and our ever changing physiological status all contribute to our very unique repertoire of behaviour. Chewing one’s nails might involve a history of intermittent social consequences (a joke, a smile, a dirty look, a reprimand), a physiological response (a taste, a sensation, a sound, a relief of discomfort), some associated covert behaviour (thoughts, emotions, images), and the impact of social norms or rules (e.g. please don’t do that beside me on the street car). Simple as the behaviour may seem at first glance, it is not so easily changed. Surely all nail biters (myself included), have been scolded for this terrible habit, have been educated on its unsavouriness and have been provided with alternatives such as the clipper or the dreaded file, but alas, the behaviour persists!

How then could a large organization of diverse professionals that supports some of the most vulnerable and complex persons in our society hope to be successful in changing such a formidable and long-standing behaviour as smoking at a psychiatric hospital?

Well, two years post implementation, the Tobacco-Free Initiative has not lead to mass staff or patient riots, an influx of lawsuits, or a complete deterioration of the therapeutic alliance.

On the other hand, it has contributed to a reduction in tobacco use on hospital grounds and less exposure of staff, clients and families to second-hand smoke in recovery-oriented areas. The discovery of cigarettes and the smell of tobacco have become much less frequent events on the inpatient unit I work on.

As a behaviour analyst, I am never satisfied with a success story. I demand to know the factors that have contributed to the change. I always find myself asking the question, “why did that work?”.

In the case of CAMH’s Tobacco-Free Initiative, I believe the success thus far can be at least partially attributed to an interdisciplinary approach that has addressed a complex issue with an equal level of procedural intricacy. Addressing systemic-political challenges through collaboration with government agencies, researchers and other health institutions, addressing physiological challenges with Nicotine Replacement Therapies and individualized interdisciplinary consultation, and addressing social challenges with behavioural intervention, health teaching initiatives, systematic staff training (including video modelling), organizational change management strategies, and a peer-based support structure have made it all possible. I believe that this function-based approach to supporting staff and clients in contributing to a tobacco free environment is critical.

The diversity of strategies and the leadership’s support of innovative approaches have also propelled the initiative forward in spite of many obstacles.

The LGUD (Forensic Rehabilitation Unit D) Healthy Lung Challenge is an intervention integrated within the Tobacco-Free Initiative,funded by the CAMH Foundation’s Gifts of Light Comfort Fund, that is based on the science of Applied Behaviour Analysis.

PiCO Monitors

Using carbon monoxide breath readers, clients within the forensic rehabilitation program have been provided with the opportunity to receive immediate feedback on the levels of carbon monoxide in their blood. Additionally, drawing upon the massive evidence base of differential reinforcement procedures, clients are able to earn prizes by producing lower carbon monoxide levels than during baseline readings. If clients produce breath samples over their baseline carbon monoxide level, they are provided with health teaching on the negative impacts of smoking. This provides not only an opportunity for learning, but also an opportunity to celebrate success in an area that traditionally focuses on failures and consequences for rule infractions.

The data thus far has been promising. The group of patients participating have demonstrated as much as a 26% reduction in blood carbon readings on average. The project is currently on its fourth iteration on LGUD and is being expanded to a second forensic inpatient unit. We are hopeful that we will continue to see positive results and provide clients with an opportunity to practice alternatives to smoking while receiving positive reinforcement for their success.



The gains that society has made in the tobacco control movement in the last 50-years have been astounding, and stand as one of the greatest social health accomplishments of the 20th century. On a smaller scale, the gains made by our own patients in LGUD reflect a commitment to overall health, one we hope can be replicated across other units. Within the framework of this success lies fantastic potential and endless possibility.

For a great read on how the science of human behaviour is driving social change and how behavioural science has been an integral part of the tobacco control movement check out The Nurture Effect by Dr. Anthony Biglan.


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