The role of action planning and plan enactment for smoking cessation

Behavioral change strategies and pharmacotherapy are often recommended for smoking cessation because they have been found to be (cost)-effective [1]. Furthermore, a problem of behavior change in general, and thus also smoking cessation, is that people may indicate a willingness to change their behavior, but often fail to act on their intentions [2, 3]. The intention-behavior gap is receiving increasing attention. One of the recommended strategies to overcome this gap pertains to goal setting; persons undertake specific actions in order to carry out their intentions. Translating an intention into behavior requires self-regulative strategies that entail both cognitive and enactive acts, strategies that we refer to as action planning [4–8]. The latter has been found to be an effective way of bridging the intention-behavior gap for both health and patient education [8–17].

Several descriptions of action planning are available [5, 9, 14, 16–19]. The commonality shared by the various descriptions is that action planning implies a sequence of behaviors used to translate an individual’s intention into specific actions in order to achieve a desired behavior goal [20]. Action planning – as for instance outlined in the I-Change Model [8, 21, 22] – can be described as the process of planning and executing specific actions that may help to adopt successfully and maintain a new health behavior. Action planning thus refers to the process by which a person aims to translate intentions into the goal behavior by setting various detailed plans – action plans – to carry out and maintain this goal behavior [23]. Effective action planning is more likely to occur when persons are motivated to change [5, 17, 24].

Goal setting refers to the end-goal that one wishes to accomplish [25, 26], and action planning refers to the choice of actions needed to achieve this goal and is comparable to setting proximal subgoals and using specific task strategies. Attainable action plans contribute to increased self-efficacy and task persistence, and will increase the likelihood of achieving the goal [27, 28]. The beneficial effect of action planning is also acknowledged by Bagozzi [4, 29], who discusses the importance of preparatory actions in the process of translating an intention into behavior [12]. The importance of action plans is also acknowledged by the Transtheoretical model by identifying various processes of change by which individuals seek new information and find alternatives for their unhealthy behavior [30]. In addition, action planning has similarities with performance objectives as described by Bartholomew and colleagues [31], which pertain to the exact performances (actions) a person needs in order to achieve a final learning objective.

Action planning can entail at least two types of actions: preparatory actions and coping actions. Preparatory actions are actions that a person needs to undertake to prepare the behavior-change attempt [16, 32–34]. Coping actions refer to actions needed to cope with difficult situations that may endanger the maintenance of the newly acquired health behavior [13, 14, 17, 35]. Planning preparatory and coping actions may require a substantial amount of self-regulative effort. This contrasts with a particular type of action plan that is referred to as implementation intentions. Implementation intentions require less self-regulation, because their formation consists of actions that will (almost) automatically be executed when a specified cue occurs [5]. Although the application of implementation intentions can lead to significant effects [36], some studies found no effects aof implementation intention interventions on behavior [37–40]. One explanation for this lack of effects may lie in the fact that intention formation outside the laboratory consists of self-chosen plans [14], which are not necessarily effective plans. In sum, action planning, as referred to in the I-Change model, encompasses a range of different types of planning strategies that may differ in their level of self-regulation.

With regard to smoking cessation, several recommendations for action plans can be found in the literature as well as cessation guides, such as: planning to remove all tobacco products from the house; planning to ask guests not to smoke inside; planning to inform friends that you are about to quit; planning how to cope with withdrawal symptoms; planning to remain smoke free when feeling stressed, sad, or down; planning how to remain smoke free when seeing others smoke or ashtrays (for more examples, see [41, 42]). Yet, little research has been done to test the efficacy of these plans in the process of smoking cessation. Moreover, some plans may be more effective for quitting, but may not necessarily be instrumental in achieving long-term change. Not all plans (or strategies as they are also known) may be effective. For instance, switching to “light” cigarettes has been found to be ineffective [43]. Hoving and colleagues [41] as well as Scholz and colleagues [44] found that action planning was positively related to successful quitting. Van Osch and colleagues [16] demonstrated that the addition of making coping plans in a Quit and Win campaign led to significantly higher quit rates. Hilberink and colleagues [42] found that Chronic Obstructive Pulmonary Disease (COPD) patients who were motivated to quit smoking within the next six months made significantly more action plans than those planning to quit smoking within the next year [42]. Yet, these studies did not assess which particular plans were predictive for smoking cessation.

Intuitively, the most important aspect of choosing particular action plans lies in their successful enactment [45]. However, one study revealed that, when given the opportunity, smokers actually used very few action plans in their smoking cessation attempt [22]. In order to be able to motivate smokers to choose effective plans, we need to know the efficacy of specific plans. Although goal setting implies both action planning and plan enactment [6, 12, 26, 31], little research is available describing the contributions of both planning and plan enactment.

This longitudinal study analyzed the role of action plans and their enactment in predicting attempts to quit and smoking cessation after one and six months. First, we describe which plans were chosen and which were enacted. Second, we examine which plans were related to attempts to quit and smoking cessation. Next, we test four hypotheses: Hypothesis 1, which is congruent with notions formulated by Sheeran, Webb, and Gollwitzer [24], states that individuals who intend to quit smoking within the next month will exhibit higher levels of planning than those intending to quit within a longer period of time. Hypothesis 2 states that higher levels of intention (Hypothesis 2a) and planning (Hypothesis 2b) will also lead to higher levels of plan enactment. Additionally, we postulate that higher levels of planning (Hypothesis 3) and plan enactment (Hypothesis 4) will be positively related to future smoking cessation behavior. Since planning is more likely to occur among smokers motivated to quit within a short period we will also assess whether the effects of specific plans will be different for smokers who are prepared to quit within one month.

Ethical approval for this study was obtained from the Medical Ethics Committee of the Academic Hospital Maastricht and Maastricht University.

Planning can have a significant positive impact on changing health behavior [55–59]. However, relatively little is known about which factors are related to action planning and plan enactment, and how they are related to smoking cessation. Our results suggest seven plans that were related to smoking cessation at follow-up after six months. The multivariate analysis identified that the execution of two specific plans was most significantly related to abstinence at follow-up, namely removing all tobacco products from the house and choosing a specific date to quit. The latter finding confirms the previous work of Balmford and colleagues [60]. Yet, it is conceivable that the five plans that were not significant anymore in the multivariate analysis are related to these two plans and that for selection of effective plans to quit smoking, a practitioner might want to choose to recommend these seven plans. In addition, we identified plans that were not related to smoking cessation after one and six months. They included finding a buddy with whom to quit, making non-smoking agreements, and thinking about how to cope with difficult situations before attempting to quit. The latter finding is in contrast to other notions of the importance of coping plans. One explanation is that this type of formulation may have been too broad and may need to be replaced by specific implementation intentions for specific difficult situations.

As suggested by Hypothesis 1, higher levels of action planning were observed in smokers who intended to quit within the next month. Additional factors that correlated with baseline action planning were being older, being female, high levels of cigarette dependence, perceiving more positive consequences (pros) of quitting, perceiving more negative consequences (cons) of quitting, and having high self-efficacy toward quitting. Although the importance of these factors for predicting successful quitting in (subgroups of) smokers has been documented by several other studies (see e.g., [30, 61–64]), their relation to the process of action planning was not assessed.

In line with Hypothesis 2, our results reveal that the intention to quit and action planning at baseline had a significant and positive influence on the number of plans executed. Other studies have already noted that action planning will be more likely to occur under high levels of motivation [5, 17, 58], but not that these factors are also related to plan enactment. Participants who intended to quit smoking within the next month had executed, on average, two and a half more action plans at follow-up one month later than their peers who intended to quit within a year. These findings are confirmed by a recent study that found the greatest effect of preparatory planning among smokers who tried to quit by following a group course [65]. At the six-month follow-up, the effect of intention was no longer significant, and action planning at baseline was the only significant predictor of plan enactment.

We found support for Hypothesis 3 stating that planning is associated with quit attempts and smoking cessation. Several plans have been found to be associated with quit attempts and smoking cessation. Yet, when controlling for other factors we noted that the general factor of planning was only a significant predictor of smoking cessation at first follow-up and only for smokers in preparation. We also found support for Hypothesis 4, postulating that plan enactment would significantly predict non-smoking status at follow-up. Other significant predictors of smoking cessation were depression, and self-efficacy. Of interest is the fact that our findings do not strongly support studies that suggest an important role for cigarette addiction in understanding cessation maintenance [66, 67]. We only found a borderline significant effect of cigarette dependence in predicting smoking cessation in the total population at the last-follow up.

Another finding was that baseline action planning was not a significant independent predictor of cessation outcome after controlling for other factors, including plan enactment. These results suggest that the effects of action planning may be mediated by plan enactment. We indeed found support for this mediation effect, since our results estimated that 81% of the direct effect of action planning was mediated by plan enactment. Furthermore, our results revealed that 29% of the smokers who completed fewer plans than the median had quit successfully after six months versus 59% of the smokers who completed more than the median. Action planning is an important precondition for plan enactment, because planning is obviously more likely to lead to enactment of certain goals. Plan enactment after one month was predicted by baseline intentions and baseline action planning and, after six months, only by action planning. This last finding illustrates the importance of translating global baseline intentions into specific plans.

Comparing the findings concerning the plans made and executed between our total population with those prepared to quit within one month showed similarity in the plans made and executed. A notable difference was the significance of breaking habits at the last follow-up, which appeared to be a significant predictor of smoking cessation among those prepared to quit. This finding supports other research that outlines the impact of habits on behavior [68], but even the importance of planning to break habits. We also found that smokers motivated to quit within one month had executed more plans. This suggests that adopting and executing effective plans can be productive to aid smoking cessation. This is supported by our finding showing that those who completed more plans than the medium were also more effective in remaining non-smokers after six months.

Our study is subject to some limitations. First, we did not assess differences in levels of specificity of the action plans. Van Osch and colleagues [16] found that plan specificity positively predicts point prevalence abstinence; medium to highly specific planning resulted in higher abstinence rates than less specific planning. Hence, assessing levels of specificity in future studies is recommended. Second, we did not make two separate scales of preparatory plans and coping plans in order to assess a potential different impact of both types of plans. Sniehotta, 2005 [13]; Sniehotta, 2009 [14]; de Vet, 2011 [34], nor did we assess the exact timing of plan enactment (e.g. before or after the quit attempt). Future studies should also assess the role of both types of planning [69] and assess the potential differential impact of preparatory and coping plan enactment. Third, our study had low retention rates at follow-up. However, because only low educational level and having a partner that smokes were related to dropout, the likelihood of a bias that those who quit smoking were more likely to provide follow-up data is small.

Our results reveal clearly the importance of the assessment of both action planning and plan enactment, factors that were also identified in a recent review of behavior-change strategies for smoking cessation [70]. Application of these behavior change strategies can be used by various methods such as mass-media campaigns, health counseling, and computer tailoring [16, 62, 71–73]. Our results support notions identified by others, such as Zhou and colleagues [74] indicating that motivational factors may be relevant for predicting smoking cessation attempts, but that other factors are also involved when predicting smoking cessation maintenance. Future studies about action planning should not only assess which plans are made but also which plans are enacted. Our study reveals that smoking cessation is more likely to be successful when effective action plans are both formulated and executed. Our study also suggests that not all action plans are necessarily predictive of effective smoking cessation. Haug and colleagues [64], for instance, found that some constructs of the Transtheoretical model (i.e., helping relationships, commitment to change, coping with temptations) were univariately related to smoking cessation, but did not have a unique prediction in a more comprehensive model. This illustrates the importance of longitudinal and experimental research as well as the use of a comprehensive model to identify which factors predict smoking cessation. Furthermore, it is relevant to study differences in decision-making for volitionally chosen and assigned action plans [45]. Although participation in goal setting may increase goal commitment [75], it is also conceivable that participants may choose ineffective action plans, as can be seen from the results in our study. Yet, it may be likely that a goal chosen with a high degree of confidence in the decision-making procedure used is more likely to be enacted than one fraught with uncertainty [76]. This suggests that action planning and levels of self-efficacy toward planning enactment may have interactive effects. Finally, some studies suggest the importance of unplanned attempts to quit, but cannot really exclude whether or not action plans were not made, and used retrospective designs (see e.g., [77–79]). Other studies do not support these claims (see e.g., [80, 81]). Our study clearly demonstrates that discussions about whether or not to use planning need better documentation than has been made in the past, namely by a clear assessment of plans made and enacted.

HdV is professor in health communication at Maastricht University with a special interest in testing social cognitive models, designing computer tailored eHealth interventions, and various other types of health communications for various topics. ME is researcher in health communication at Maastricht University with special interests in theory building and testing and HIV prevention. CB is assistant professor in health psychology with special interests in smoking cessation.