Most attempts to quit smoking fail. Borland et al. [1
] recently estimated that the average smoker makes around 1 unsuccessful quit attempt per year, defining attempts as quitting for at least a day. They found around 40% reporting attempts (average around 2 each), but that at least 20% of attempts are forgotten within the year. Smokers also report a similar number of aborted attempts (plans to quit that did not achieve 1 day of abstinence). This represents a lot of failed effort. Other researchers have estimated that only 3-5% of smokers are able to achieve prolonged abstinence for 6–12 months after a given unassisted quit attempt [2
], an estimate consistent with the high levels of failure. Relapse is most common within the first week [2
]. Good quality structured support and advice increases smoking cessation rates over those achieved in self-managed attempts, independent of any effect attributable to use of pharmacotherapy [3
], but effects of both kinds of intervention are modest. However, evidence suggests little or no success in reducing relapse beyond the early days of an attempt [4
]. There is a need for better strategies to reduce relapse.
It is widely believed that planning for a difficult task like quitting smoking should result in increased success. The importance of planning is emphasized in stage-based models of behaviour change [6
], and is implicit in models that specify the factors leading to the formation of a behavioural intention, such as the Theory of Planned Behaviour [7
]. Smoking cessation guidelines for health professionals e.g., [8
] typically recommend that smokers be encouraged to set a quit date in the future (usually 1–2 weeks later), and to prepare for this date using a range of strategies including dealing with perceived barriers to quitting, seeking social support, considering the use of pharmacotherapy or behavioural assistance, keeping a smoking diary to better understand triggers to smoke, and developing coping strategies to deal with them.
Recently, theoretical and empirical developments have led to a questioning of the primary importance of planning for quit success. PRIME theory, a comprehensive theory of addiction proposed by West [11
], has drawn attention to the instability of motivation [see also [12
]; Borland, forthcoming] and to the primacy of impulses and emotions in the motivational system. According to the theory, smokers may experience ‘tension’ or dissonance about their smoking over a period of time without being moved to action, until a precipitating event occurs that triggers action. When a quit effort is triggered by such an ‘epiphany’, it may be launched with a motivational momentum that increases the likelihood of success. Delaying a quit attempt following such an event in order to plan for it may be detrimental, as it can lead to a decline in motivation over the planning period, thus resulting in the attempt being made on average during a period of reduced motivation. Related to this several recent studies, using retrospective reports, have found that those who successfully quit (typically stopped for more than 6 months) have been more likely to report that their quit attempt was spontaneous, i.e. occurred as soon as the decision was made, rather than allowing a period for planning, than those who reported a failed attempt [13
]. A study of ours found much more complex patterns with some evidence of shorter planning periods associated with less success, but no effect for longer delays [18
]. Population-based retrospective studies of cutting down to quit (a form of preparatory planning and something that precludes spontaneous quitting completely) find it also results in less success than abrupt cessation, even among attempts that result in a period of cessation [19
At this point, it is premature to conclude that delay is detrimental. The Murray et al. [15
] paper provided some evidence that at least some of the effects are due to differential forgetting. Forgetting could be because a lead-in period increases the duration and thus potential salience of the event for any given length of time quit, and does this proportionately more for short attempts. Alternatively, pre-quit periods might be disproportionately likely to be forgotten with time quit as they form a smaller part of the total event. However, if the effects are real, it suggests that some forms of preparatory activity are counterproductive. Borland’s (forthcoming) dual process theory of behaviour emphasises the continually changing, environmentally cued, reactive tendency to smoke, and argues that self-regulatory functions need to be able to sustain a level of motivation for change sufficiently long for both a quit attempt to be initiated and for it to become a stable new behaviour pattern. This requires effort, which is prone to be exhausted [20
]. As effort is required in the preparatory stages, delay will bring forward the point of exhaustion, all other things being equal. So unless preparatory activity actually leads to the task becoming easier at a faster rate than the effort involved leads to exhaustion, relapse will be more likely under conditions of delay.
Up to around half of quit attempts are reported to start immediately the decision is made [13
]. Cooper et al. [18
] also found that a minority of attempts begin after a period of abstinence for other reasons (e.g. being too ill to smoke), with only around half delaying implementation. Qualitative research [15
], an in-depth empirical study following smokers on a day by day basis [12
], and our own work all point to greater complexity regarding what is meant by both spontaneity and planning. First, implicit in West’s model is that spontaneity relates to peaks in fluctuating levels of longer-term concern; that is, that ‘spontaneous’ quit attempts are typically preceded by periods of deliberation that are not strong enough to trigger action, rather than occurring completely out of the blue. Certainly, a lot more smokers report thoughts of quitting than go on to try in any given period of time [1
]. Second, planning may be able to be carried forward from previous, especially recent attempts. Third, our work has found that a proportion of those reporting spontaneous quits also report cutting down to quit and/or using medications (e.g., Varenicline) that require a period of use prior to stopping smoking (unpublished data). Clearly these do not represent cases of spontaneously fully implementing a quit attempt.
There is clearly ambiguity as to what constitutes a spontaneous attempt and how that relates to planning. First, what has been caught up under ideas of spontaneity really covers two quite distinct concepts: the spontaneity of the decision to quit (i.e., whether it is made without any preparatory thought or related activity); and the immediacy of implementation (i.e., whether implementation occurs immediately the decision to quit is made or with some delay). Implementation can also either refer to stopping completely (full implementation), or beginning a process that will lead to full implementation; e.g., arranging for a doctor’s appointment to get prescription medication, beginning a period of preloading with medication, or starting a cut-down schedule. Where implementation is staged, the actual quit date might not be set until reaching the target window for quitting (e.g., for Varenicline from 1–2 weeks after initiating use), and implementation could then be ‘immediate’ or sometime in the future (delayed). This analysis suggests that it may be useful to distinguish four key concepts, defining a spontaneous attempt as one where the decision or process of deciding is initiated without any prior forethought (at least recent); delay in initiation as a gap between the decision to act and the initiation of the attempt; initiation of implementation as beginning to perform any action necessary to the chosen approach (e.g. obtaining medication); and full implementation as actually stopping smoking completely.
We now turn to a similar analysis of planning, or more correctly, pre-planning, as we are not considering on-the-spot planning to deal with actual challenges. The term ‘planning’ can refer to a wide range of possible activities from simply forming some intention to act (I am planning to quit), through to various forms of preparatory activity. The research referred to above has tended to assume that planning must occur before action, and that spontaneous attempts preclude the possibility of planning. It is true, where a spontaneous decision is fully implemented immediately, that there is no opportunity to pre-plan a quit attempt. Otherwise, there is the possibility of conditional planning (i.e. before deciding to quit) or of engaging in planning between making the decision and full implementation. However, while delay provides the opportunity to plan, it does not mean it will happen.
There are some aspects of planning that must by necessity occur before full implementation, such as deciding on how to quit (abruptly or by cutting down), whether to use help such as Varenicline that should start before actually quitting, and planning activities like keeping diaries of cigarettes smoked. However, many aspects of planning can equally occur before or after quitting, such as planning for high-risk situations and seeking social supports. Anticipating and forming strategies to deal with events that may precipitate relapse can occur after a quit attempt has started, though situations that will be encountered early on, such as dealing with strong situational cravings, would have to be prioritized. Assuming the person is not already craving a cigarette when they make the decision to quit, they should have some time to plan before any serious cravings occur, and except for the minority who experience almost continual cravings, should have time between bouts of craving to plan for future instances, even if they have to deal spontaneously with a couple of unplanned-for episodes of craving before their planning is complete. Certainly, the notion that the sequence must be to decide, plan, then implement is by no means a necessity, and what limited data we have suggests it is by no means the norm. There is also no good evidence as to whether the timing of these activities has any effect on their utility.
It is also plausible that the quality of planning is at least as important as its presence. Recent research has shown that a form of planning called an implementation intention can improve outcomes [22
]. An implementation intention is a self-statement of the form when or if some specified event occurs, I will engage in some specified protective action; e.g., ‘when I get a craving to smoke while with my friend Jim, I will remind him that he has agreed to help me stay quit’. A meta-analysis of 94 studies found forming implementation intentions to have a medium-to-large effect on goal attainment, over and above the impact of forming relevant goal intentions [23
]. More recently implementation intentions have been shown to facilitate ongoing goal striving (relapse prevention), protecting individuals from the influence of potentially disruptive inner states such as cravings [24
]. It appears to be a new and important strategy for getting people to implement plans at the appropriate time. That said, all of the studies to date have either been of relatively straight-forward behaviours, or have only considered short term outcomes for more complex ones like smoking.
This study is designed to test (a) the potential benefit of structured support for planning, and (b) the potential benefit of recommending an immediate start to the implementation of a quit attempt.
Conducting RCTs of events where choice is under the control of smokers rather than researchers/clinicians is always complicated and often requires compromise. It is particularly problematic when smokers’ spontaneous choices might contribute to the therapeutic effect. We cannot randomize spontaneity, but independent of whatever pre-decisional planning smokers have engaged in, we can randomize to encouragement to quit at one time or another, and to the provision of structured help to facilitate planning, but are limited in our ability to constrain the timing of the planning that is undertaken.
Advising people to stop smoking immediately is unlikely to be a sensible intervention strategy because it precludes use of the forms of help that require a period of pre-quit use (e.g. Varenicline). Immediate implementation is defined here as immediately taking whichever ‘next step’ is required to ensure that the quit attempt takes place without avoidable delay, and only for some will this be stopping immediately. We will record instances of unavoidable delay, to see if this makes a difference.
In this study, we will recruit a group of smokers at a time when their motivation to quit is high, and at the point at which they seek cessation assistance, but who are not sufficiently advanced in their progress towards becoming an ex-smoker to preclude the provision of either or both interventions. The use of web-based cessation help is an ideal setting, as smokers can access it when considering quitting and there need be no delay. While some smokers access this form of help after quitting, most do so before, including many who have not yet committed to an attempt [25
]. The QuitCoach [26
], a demonstrably effective Internet-based automated tailored advice program developed by the authors [27
], is designed to assess a smoker’s situation and provide immediate assistance. Users complete a 10-minute online assessment and receive tailored advice based on their answers, which can either be read on screen or downloaded as a PDF document. The program is designed to be used on multiple occasions, with return to the site recommended after a significant change has taken place, such as actually initiating a quit attempt, or to prevent relapse.
The primary hypotheses are that among smokers who seek help from QuitCoach, 6 month sustained abstinence will be greater among:
1. those encouraged to begin to implement a quit attempt immediately as compared with those supported to quit to their own timetable); and
2. those who are provided with a structured planning program with prompts to engage in planning activities and encouragement and supported to form implementation intentions as compared with those only provided motivational messages and general encouragement to plan.
Secondary aims are to:
1. test for any interaction between the two interventions, particularly to see if the two add value when combined;
2. test the hypothesis of a dose–response relationship for actual use of the planning resources and with other planning activity;
3. test whether more dependent smokers will be more likely to benefit from the planning intervention;
4. test whether smokers with a recent history of quit attempts and those who report at baseline that they have already engaged in planning will be less likely to benefit from the planning intervention; and
5. explore the relative benefits of the timing of planning (e.g., more before vs more after) on success.