A study protocol for a randomised controlled trial evaluating the use of information communication technology (WhatsApp/WeChat) to deliver brief motivational interviewing (i-BMI) in promoting smoking cessation among smokers with chronic diseases

The technique was introduced by Freeman and Fraser [14] for investigating individuals’ compliance without pressure. It emphasizes the notion that individuals who are induced to comply with a smaller and easier request initially are more likely to comply with and achieve a larger request [14]. Their agreements for the first requests or targets increase their confidence and alter their attitudes towards themselves that they are capable and willing to take further actions.

MI was originally developed in the field of addictions and found to be transferable to other health-related behaviours including smoking cessation [15, 16]. However, traditional MI generally takes over 30 min to implement and is not feasible in busy clinical settings. A brief MI [17] was thus developed with the aim to provide brief consultations in medical settings. Brief MI shares the same core as MI that individuals are advocates to initiate and continue behavioural change, and yet often in a state of ambivalence with fluctuating motivations before the behavioural change. Brief MI and MI therefore focus on using specific techniques to explore and resolve the ambivalence, develop discrepancies between individuals’ core belief and the behaviour of not engaging in desirable health-related lifestyle practice, consequently enhancing the confidence and motivation in the behavioural change. Brief MI emphasizes on adopting shorter and simpler strategies, which include opening strategy, a typical day, the good things and the less good things, providing information, the future and the present, exploring concerns and helping with decision-making.

The foot-in-the-door technique will be incorporated into the conceptual basis of the intervention to facilitate the recruitment process and enhance compliance of smokers. According to previous studies, most smokers with chronic diseases have had no intention to quit [5‐7]. However, they were found to be interested in promoting their health [12, 13]. Through asking these smokers to identify, change and engage in their desirable health-related behaviours (a smaller and easier request), it is expected that they will be more motivated to quit smoking (a larger request) in later time.

To guide the process of behavioural change, brief MI will be used to provide a strong theoretical framework to the intervention. Most importantly, we use Information Communication Technology, i.e. WhatsApp/WeChat, to provide brief MI via smart phone. Accordingly, we will start the conversation in WhatsApp/WeChat messengers by asking the smokers about their current stress and lifestyles that are related to health, so as to establish a collaborative relationship and have a general understanding about the smokers (opening strategy). To further comprehend the context of not engaging in the desirable health-related lifestyle practice, we will review a typical day of the smokers (a typical day) and ask about the pros and cons of not adopting the desirable health-related lifestyle practice (the good things and the less good things). The smokers will receive further information about that if he/she is interested (providing information). To elicit the discrepancy, the smokers will be encouraged to talk about his/her ideal future, compare the past and the present (the future and the present). We will also listen, explore and summarize the concerns with the smokers (exploring concerns). To resolve the ambivalence, we will further describe what others have done in a similar situation, and present options while not pushing the smokers for decision making (helping with decision-making). Importantly, the confidence will be enhanced throughout the process of giving health advice by encouraging the smokers to be aware of any resource that enables and facilitates the change. By using such a strategic approach, the smokers will realize the discrepancy, be motivated and discuss an action plan for adopting the new desirable health-related lifestyle practice.

After completing the baseline questionnaires, the trained research assistant will first ask the subjects about the priority of engaging in any desirable health-related lifestyle practice as identified in the completed baseline questionnaires (i.e. smoking reduction or quitting, regular physical activity, healthy diet and reduce alcohol consumption). The subjects will also ask to state a targeted goal in which they perceive as the easiest to achieve, such as eating more vegetables, eating less salted or fried food, engaging in more or higher intensity of exercise, reducing alcohol consumption, reducing number of cigarette consumption per day or quitting. Each subject will then receive an individual face-to-face brief MI (about 5 min) with generic health advice on selected health-related lifestyle practice. All subjects will then be informed that they will receive an individual brief MI intervention to assist behavioural changes or achieve goals as desired or chosen by them via WeChat or WhatsApp in the smart phones throughout the study period. In addition, the subjects will be given a self-help smoking cessation booklet with a public quitline number.

The trained research assistant will deliver brief MI to each subject in the intervention group individually via WeChat or WhatsApp in the smart phones throughout the study period. The brief MI messages will be delivered more intensively as preferred by the subject (usually not less than once per 2–3 days and no more than 2 times per day) for the first 6 months. The frequency of delivering message through WeChat or WhatsApp will be interactive, depended on subjects’ actions and responses. It may take several sessions of chats within several days/weeks. However, the total time spent by the research assistant would not be more than that for traditional MI with several long sessions.

Start from 6 months, minimal messages by merely following the subjects’ progress and responding to their questions to maintain contact will be provided to subjects till one-year follow-up.

The content of the brief MI messages will depend on the desirable health-related lifestyle practice and the targeted goal in which the subjects perceive as the easiest to achieve. The trained research assistant will give brief MI messages with an aim at moving the subjects towards the goal. The brief MI messages will be guided by the menu of strategies (Table 1). As the trained research assistant moves down the menu, greater readiness to change from the subjects will be required. During the process of delivering brief MI via WeChat or WhatsApp, the trained research assistant will follow the menu of strategies and start from the top. To begin the conversation, the trained research assistant will first explore the subjects’ current barriers and facilitators, and lifestyles by asking, ‘What are your current lifestyle practice in general?’, and ‘What are your current barriers and facilitators?’ The trained research assistant will then raise the topic of not engaging in desirable health-related lifestyle practice with open-ended question such as ‘How does your current lifestyle practice fit in? ‘How does your current lifestyle practice affect your health?’ After that, the trained research assistant will ask the subjects to describe a typical day with how the current lifestyle practice fit in. In this strategy, it is important to train the research assistant to be aware not to push the subjects nor to insert their own hypothesis into the conversation. The trained research assistant will then bring the pros and cons of the subjects’ current lifestyle practice by questions such as ‘What are some of the good things/less good things of your current lifestyle practice?’. When the subjects become curious about the current or the desirable health-related lifestyle practice, the trained research assistant will ask for permission before providing relevant information by questioning ‘I wonder if you would be interested in knowing … ’. The trained research assistant will elicit a discrepancy by asking an open-ended question such as ‘How would you like things to be in the future?’. To explore the concerns, the trained research assistant will raise questions, ‘What concerns do you have about engaging in desirable health-related lifestyle practice?’ and ‘What other concerns do you have now?’. When the concerns are clearly manifest, an open question like, ‘What does this leave you now?’ can help subjects to decide the future actions. The research assistant will be trained to summarize subjects’ statements constantly throughout the conversation.

Also, the technique of expressing empathy will be incorporated in the intervention so as to develop a genuine and closer relationship of caring with the subjects. Expressing empathy is a specifiable and learnable skill for understanding another’s meaning through the use of reflective listening [16]. To incorporate such skill into the intervention, the trained research assistant will be reminded to show respect in the messages, especially not to impose direction and judgment regarding the subjects’ decision. Also, throughout the conversations, the attitude of the research assistant should be acceptance, but not necessarily approval or agreement. Besides, the research assistant will be reminded that ambivalence is normal and they should avoid forcing the subjects to change [16].

Although subjects do not have an intention to quit smoking at baseline (one of the inclusion criteria), the readiness of quitting smoking will be assessed at 3-month follow-up. For those who are willing to take further actions to promote their health, i.e. with an intention to quit smoking, health advice on smoking will be given with more emphasis on the health benefits of quitting. Upon request by subjects, we shall provide them with more comprehensive information on quitting. Specifically, the intervention should address the needs of smoking patients by teaching them with the skills to overcome withdrawal symptoms or cigarette cravings. In addition, subjects will be allowed to select their own schedules of quitting, such as to quit immediately or progressively. Our previous randomised controlled trial on the effectiveness of a self-determination intervention for smoking cessation (immediate or progressive) among people attending emergency departments showed that by giving autonomy for smokers to select their own schedules of quitting would enhance their self-efficacy and competence in quitting smoking. For those who request nicotine replacement therapy (NRT) to assist them quitting, we shall refer them to a smoking cessation hotline in which free sample of NRT will be offered. The whole intervention will be given to the subjects through WeChat/WhatsApp during the process of the study. However, we understand that older people always appreciate regular phone conversations intermingled with message. Hence, there will be a follow-up telephone call with our subjects each month for the first 6 months so as to further build a closer relationship with them.

A registered nurse with more than 5 year of experience in delivering smoking cessation interventions will be employed as the research assistant for this study. This registered nurse has already trained to use brief MI to provide face-to-face smoking cessation advices. However, to ensure that she will fully comply with our protocol, a half day training workshop by the research committee (principal and co-investigators) will be offered to her before this study. The workshop will include the principles and practices on brief MI and healthy lifestyles. The skills of brief MI will be co-learnt between the registered nurse and the principal and co-investigators through demonstrations and return demonstrations. Significantly, case study examples will be thoroughly discussed via role playing to permit the registered nurse to understand and practise the required skills. To ensure the quality and competence of the registered nurse in applying the learnt skills before implementation, she will be needed to complete an assessment with a case study examination after the workshop. The assessment will be performed by one of the research committee members who has expertise in using brief MI.

Before randomisation, the subjects will be invited to complete a structured questionnaire, administered by a trained research assistant face-to-face. This structured questionnaire will be developed through adopting or modifying international and/or locally validated instruments. The questionnaire will gather information including smoking and quitting history, stage of readiness to quit, utilization of existing smoking cessation services, and demographic information such as age, gender, and marital status. The clinical information will be obtained by the trained research assistant from the subjects’ medical records.

All subjects will receive follow-up telephone call at 1, 3, 6 and 12 months from our trained research assistant. In each telephone follow-up, the subjects will be asked to complete the structured questionnaire again. Subjects who are abstinent from cigarette use ≥7 days at 12-month follow-up will be invited for a biochemical validation. The biochemically validated 7-day point prevalence of abstinence will be confirmed by saliva cotinine level < 115 ng/ml in parallel test and a carbon monoxide level in expired air < 9 ppm (p.p.m.) [18]. These biochemical validation methods have been used in previous studies on smoking cessation [19, 20]. For subjects on nicotine replacement therapy, biochemical validation will be conducted 7 days after the completion of therapy.