Debate & Analysis

Making health habitual:
the psychology of ‘habit-formation’ and general practice
MAKING HEALTH HABITUALThe Secretary of State recently proposedthat the NHS:‘... take every opportunity to prevent poor
health and promote healthy living by making
the most of healthcare professionals’
contact with individual patients.’ 1
Patients trust health professionals asa source of advice on ‘lifestyle’ (that is,behaviour) change, and brief opportunistic
advice can be effective.2 However, many
health professionals shy away from giving
advice on modifying behaviour because theyfind traditional behaviour change strategies
time-consuming to explain and difficult forthe patient to implement.2 Furthermore,even when patients successfully initiate therecommended changes, the gains are oftentransient3 because few of the traditional
behaviour change strategies have built-in
mechanisms for maintenance.
Brief advice is usually based onadvising patients on what to change andwhy (for example, reducing saturated fat
intake to reduce the risk of heart attack).
Psychologically, such advice is designed toengage conscious deliberative motivationalprocesses, which Kahneman terms ‘slow’
or ‘System 2’ processes.4 However, theeffects are typically short-lived because
motivation and attention wane. Brief advice
on how to change, engaging automatic(‘System 1’) processes, may offer a valuable
alternative with potential for long-term
impact.
Opportunistic health behaviour advice
must be easy for health professionals to giveand easy for patients to implement to fit into
routine health care. We propose that simple
advice on how to make healthy actions into
habits — externally-triggered automatic
responses to frequently encounteredcontexts — offers a useful option in thebehaviour change toolkit. Advice for creating
habits is easy for clinicians to deliver andeasy for patients to implement: repeat achosen behaviour in the same context, until
it becomes automatic and effortless.
HABIT FORMATION AND HEALTH
While often used as a synonym for frequentor customary behaviour in everyday
parlance, within psychology, ‘habits’ aredefined as actions that are triggered
automatically in response to contextual

664 British Journal of General Practice, December 2012

cues that have been associated with theirperformance:5,6 for example, automaticallywashing hands (action) after using the toilet(contextual cue), or putting on a seatbelt(action) after getting into the car (contextualcue). Decades of psychological research
consistently show that mere repetition ofa simple action in a consistent context
leads, through associative learning, to theaction being activated upon subsequent
exposure to those contextual cues (that is,habitually).7–9 Once initiation of the action is‘transferred’ to external cues, dependence
on conscious attention or motivational
processes is reduced.10 Therefore habits
are likely to persist even after conscious
motivation or interest dissipates.11 Habits
are also cognitively efficient, because
the automation of common actions frees
mental resources for other tasks.
A growing literature demonstrates therelevance of habit-formation principles
to health.12,13 Participants in one study
repeated a self-chosen health-promoting
behaviour (for example, eat fruit, go for awalk) in response to a single, once-dailycue in their own environment (such as, afterbreakfast). Daily ratings of the subjective
automaticity of the behaviour (that is, habitstrength) showed an asymptotic increase,with an initial acceleration that slowed to aplateau after an average of 66 days.9 Missing
the occasional opportunity to perform thebehaviour did not seriously impair the habit
formation process: automaticity gains soon
resumed after one missed performance.9
Automaticity strength peaked more quickly
for simple actions (for example, drinkingwater) than for more elaborate routines (forexample, doing 50 sit-ups).
Habit-formation advice, paired witha ‘small changes’ approach, has beentested as a behaviour change strategy.14,15
In one study, volunteers wanting to lose
weight were randomised to a habit-based
intervention, based on a brief leaflet listing

10 simple diet and activity behaviours andencouraging context-dependent repetition,
or a no-treatment waiting list control. After
8 weeks, the intervention group had lost
2 kg compared with 0.4 kg in the control
group. At 32 weeks, completers in theintervention group had lost an average of
3.8 kg.14 Qualitative interview data indicatedthat automaticity had developed: behaviours
became ‘second nature’, ‘worming theirway into your brain’ so that participants‘felt quite strange’ if they did not dothem.10 Actions that were initially difficult
to stick to became easier to maintain. A
randomised controlled trial is underway totest the efficacy of this intervention where
delivered in a primary care setting to alarger sample, over a 24-month follow-up
period.16 Nonetheless, these early results
indicate that habit-forming processes
transfer to the everyday environment, andsuggest that habit-formation advice offers
an innovative technique for promoting longterm behaviour change.13
MAKING HEALTHY HABITS
We suggest that professionals could
consider providing habit-formation advice
as a way to promote long-term behaviourchange among patients. Habit-formation
advice is ultimately simple — repeat anaction consistently in the same context.12
The habit formation attempt begins at the‘initiation phase’, during which the newbehaviour and the context in which it will bedone are selected. Automaticity develops
in the subsequent ‘learning phase’, during
which the behaviour is repeated in thechosen context to strengthen the contextbehaviour association (here a simpleticksheet for self-monitoring performance
may help; Box 1). Habit-formation
culminates in the ‘stability phase’, at which
the habit has formed and its strength has
plateaued, so that it persists over time withminimal effort or deliberation.

“Advice for creating habits is easy for clinicians todeliver and easy for patients to implement: repeata chosen behaviour in the same context, until it
becomes automatic and effortless.”

“... typical [behaviour change] advice ... emphasises
variation in behaviours and settings ... . Variation may
stave off boredom, but is effortful and ... incompatible
with development of automaticity.”
Initiation requires the patient to be
sufficiently motivated to begin a habitformation attempt, but many patients would
like to eat healthier diets or take more
exercise, for example, if doing so were
easy. Patients must choose an appropriate
context in which to perform the action. The‘context’ can be any cue, for example, anevent (‘when I get to work’) or a time ofday (‘after breakfast’), that is sufficiently
salient in daily life that it is encountered anddetected frequently and consistently. A cue

located within an existing daily routine (forexample, ‘when I go on my lunch break’)provides a convenient and stable starting
point.10
Keeping going during the learning
phase is crucial. The idea of repeating asingle specific action (for example, eatinga banana) in a consistent context (withcereal at breakfast) is very different fromtypical advice given to people trying totake up new healthy behaviours, which
often emphasises variation in behaviours

Box 1. A tool for patients
Make a new healthy habit

1. Decide on a goal that you would like to achieve for your health.
2. Choose a simple action that will get you towards your goal which you can do on a daily basis.
3. Plan when and where you will do your chosen action. Be consistent: choose a time and place that you
encounter every day of the week.
4. Every time you encounter that time and place, do the action.
5. It will get easier with time, and within 10 weeks you should find you are doing it automatically withouteven having to think about it.
6. Congratulations, you’ve made a healthy habit!
My goal (e.g. ‘to eat more fruit and vegetables’) _________________________________________________My plan (e.g. ‘after I have lunch at home I will have a piece of fruit’)(When and where) ___________________________ I will ___________________________
Some people find it helpful to keep a record while they are forming a new habit. This daily tick-sheet can beused until your new habit becomes automatic. You can rate how automatic it feels at the end of each week,
to watch it getting easier.

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10
Monday										Tuesday										Wednesday										Thursday										Friday										Saturday										Sunday										Done on>5 days,
yes or no 										Howautomatic
does it feel?
Rate from1 (not at all)to10(completely)										and settings to maintain interest (trying
different fruits with or between different
meals). Variation may stave off boredom,but is effortful and depends on maintaining
motivation, and is incompatible withdevelopment of automaticity.6Patients should choose the targetbehaviour themselves. Progress towards aself-determined behavioural goal supports
patients’ sense of autonomy and sustains
interest,17 and there is evidence that abehaviour change selected on the basis of
its personal value, rather than to satisfy
external demands such as physicians’
recommendations, is an easier habit
target.18 Patients need to select a new
behaviour (for example, eat an apple) rather
than give up an existing behaviour (do noteat fried snacks) because it is not possible
to form a habit for not doing something. The
automaticity of habit means that breaking
existing habits requires different andaltogether more effortful strategies thanmaking new habits.12
Patients should be encouraged to aim forsmall and manageable behaviour changes,
because failure can be discouraging. A
sedentary person, for example, would be
more appropriately advised to walk one or
two stops more before getting on the bus
than to walk the entire route — at least
for their first habit goal. Small changes
can benefit health: slight adjustments todietary intake can aid long-term weight
management,19 and small amounts of lightphysical activity are more beneficial thannone.20 Moreover, simpler actions become
habitual more quickly.9 Additionally,
behaviour change achievements, however
small, can increase self-efficacy, which
can in turn stimulate pursuit of further
changes.21 Forming one ‘small’ healthy
habit may thereby increase self-confidence
for working towards other health-promoting
habits.
Unrealistic expectations of the durationof the habit formation process can leadthe patient to give up during the learning
phase. Some patients may have heard that
habits take 21 days to form. This myth
appears to have originated from anecdotal
evidence of patients who had received
plastic surgery treatment and typicallyadjusted psychologically to their newappearance within 21 days.22 More relevant
research found that automaticity plateauedon average around 66 days after the first
daily performance,9 although there wasconsiderable variation across participants
and behaviours. Therefore, it may be helpful
to tell patients to expect habit formation(based on daily repetition) to take around

British Journal of General Practice, December 2012 665

ADDRESS FOR CORRESPONDENCEBenjamin GardnerHealth Behaviour Research Centre, Department ofEpidemiology and Public Health, University College
London, Gower Street, London, WC1E 6BT, UK.
E-mail: b.gardnersood@ucl.ac.uk

10 weeks. Our experience is that people
are reassured to learn that doing thebehaviour gets progressively easier; so they
only have to maintain their motivation until
the habit forms. Working effortfully on a
new behaviour for 2–3 months may be an
attractive offer if it has a chance of making
the behaviour become ‘second nature’.
CONCLUSION
Psychological theory and evidence
aroundhabit-formation
generates
recommendations for simple andsustainable behaviour change advice. We
acknowledge that health professionals do
not always find it appropriate to offer lifestylecounselling to patients: some patients canbecome annoyed when advised to change
their behaviour, and this reaction canthreaten patients’ trust in and satisfaction
with the doctor–patient relationship.2
However, in settings where professionals
feel able to offer behaviour advice, wesuggest that they consider providing
guidance on habit-formation. Habitformation advice can be delivered briefly, itis simple for the patient to implement, and it
has realistic potential for long-term impact.
It offers health professionals a useful toolfor incorporating evidence-based healthpromotion into encounters with patients. A
sample tool for health professionals to use
with patients to encourage habit formation
is provided in Box 1.
Benjamin Gardner,Lecturer in Health Psychology, Health Behaviour
Research Centre, Department of Epidemiology andPublic Health, University College London, London.
Phillippa Lally,ESRC Postdoctoral Research Fellow, HealthBehaviour Research Centre, Department ofEpidemiology and Public Health, University CollegeLondon, London.
Jane Wardle,Professor of Clinical Psychology, Health Behaviour
Research Centre, Department of Epidemiology andPublic Health, University College London, London.
ProvenanceFreely submitted; externally peer reviewed.
DOI: 10.3399/bjgp12X659466

666 British Journal of General Practice, December 2012

REFERENCES

1. Lansley A. Response to NHS Future Forum’s
second report. London: Department of Health,2012. http://www.dh.gov.uk/prod_consum_dh/
groups/dh_digitalassets/documents/digitalasset/dh_132088.pdf (accessed 16 Oct 2012).
2. Lawlor DA, Keen S, Neal RD. Can generalpractitioners influence the nation’s healththrough a population approach to provision oflifestyle advice? Br J Gen Pract 2000; 50(455):
455–459.
3. Jeffery RW, Drewnowski A, Epstein LH,
Stunkard AJ, et al. Long-term maintenance of
weight loss: current status. Health Psychol 2000;
19(Suppl1): 5–S16.
4. Kahneman D. A perspective on judgment andchoice. Am Psychol 2003; 58(9): 697–720.

12. Lally P, Gardner B. Promoting habit
formation. Health Psychol Rev . In press: DOI:
10.1080/17437199.2011.603640.
13. Rothman AJ, Sheeran P, Wood W. Reflective
and automatic processes in the initiation andmaintenance of dietary change. Ann Behav Med
2009; 38(Suppl1): S4–17.
14. Lally P, Chipperfield A, Wardle J. Healthy habits:
Efficacy of simple advice on weight control basedon a habit-formation model. Int J Obes 2008;
32(4): 700–707.
15. McGowan L, Cooke LJ, Croker H, et al. Habitformation as a novel theoretical framework for
dietary change in pre-schoolers. Psychol Health2012; 27(Suppl1): 89.

5. Neal DT, Wood W, Labrecque JS, Lally P. How
do habits guide behavior? Perceived and actual
triggers of habits in daily life. J Exp Soc Psychol
2012; 48: 492–498.

16. Beeken RJ, Croker H, Morris S, et al. Study
protocol for the 10 Top Tips (10TT) Trial:
Randomised controlled trial of habit-based
advice for weight control in general practice.
BMC Public Health 2012; 12(1): 667.

6. Wood W, Neal DT. A new look at habits and thehabit-goal interface. Psychol Rev 2007; 114(4):843–863.

17. Deci EL, Ryan RM. The support of autonomy andthe control of behavior. J Pers Soc Psychol 1987;
53(6): 1024–1037.

7. Bayley PJ, Frascino JC, Squire LR. Robust
habit learning in the absence of awarenessand independent of the medial temporal lobe.
Nature 2005; 436(7050): 550–553.

18. Gardner B, Lally P. Does intrinsic motivation
strengthen physical activity habit? Modeling
relationships between self-determination, past
behaviour, and habit strength. J Behav Med[Epub ahead of print].

8. Hull CL. Principles of behavior: an introduction
to behavior theory. New York, NY: AppletonCentury-Crofts, 1943.
9. Lally P, van Jaarsveld CHM, Potts HWW, Wardle
J. How are habits formed: modelling habit
formation in the real world. Euro J Soc Psychol
2010; 40: 998–1009.
10. Lally P, Wardle J, Gardner B. Experiences ofhabit formation: a qualitative study. Psychol
Health Med 2011; 16(4): 484–489.
11. Gardner B, de Bruijn GJ, Lally P. A systematic
review and meta-analysis of applications of theSelf-Report Habit Index to nutrition and physicalactivity behaviours. Ann Behav Med 2011; 42(2):174–187.

19. Hill JO. Can a small-changes approach help
address the obesity epidemic? A report of theJoint Task Force of the American Society for
Nutrition, Institute of Food Technologists, andInternational Food Information Council. Am J
Clin Nutr 2009; 89(2): 477–484.
20. Warburton DER, Nicol CW, Bredin SSD. Healthbenefits of physical activity: the evidence. Can
Med J 2006; 174(6): 801–809.
21. Bandura A. Social cognitive theory: an agentic
perspective. Annu Rev Psychol 2001; 52: 1–26.
22. Maltz M. Psycho-cybernetics. New York, NY:
Prentice Hall, 1960.