The effect of a very brief smoking-reduction intervention in smokers who have no intention to quit: Study protocol for a randomized controlled trial

Tobacco use is one of the most common preventable causes of death, and many countries are expending effort to reduce the smoking prevalence. However, the prevalence of smoking in China has declined little in recent years. The Global Adult Survey reported that the prevalence of smoking among Chinese men decreased from 57.4% in 2002 to 52.9% in 2010 [1,2]; thus, more than half of Chinese men are still current smokers. Although quitting can reduce the mortality due to smoking-induced diseases, 63.6% of Chinese smokers would not consider quitting [2]. Therefore, it is critical to expand smoking prevention and cessation efforts in China.

In developed countries and regions, including Hong Kong and Taiwan with mostly Chinese [3-6], smoking cessation services, such as smoking cessation clinics and telephone quitlines, are well established. These services play an important role in public health. However, these specialized and intensive smoking-cessation services are too expensive and passive to have major clinical and public health impacts in developing countries like China, as they require continuous and enormous funding and intensive training for counselors, and involve other costs, such as pharmacotherapy. Pharmacotherapy is an effective treatment modality for tobacco dependence, but it is not widely used in China mainland [7,8]. One of the most important reasons why pharmacotherapy is not widely used for smoking cessation is that smoking-cessation medications are not covered by medical insurance, and they are too expensive. Hence, there is an urgent need for a much cheaper yet effective strategy for helping smokers to quit.

In general, commonly used behavioral intervention categories fall into two categories: brief or minimal interventions and intensive interventions [9]. A brief or minimal intervention was defined in a Cochrane review as less than 20 minutes of advice plus up to one follow-up session [10]; other interventions were defined as intensive. Stead et al. reported that the quit rate following brief advice from physicians was significantly higher than that following no advice (or usual care); the relative risk (RR) was 1.66, and the 95% confidence interval (CI) was 1.42 to 1.94 [10]. However, the quit rates following intensive counseling were not found to be significantly different from those following brief counseling in two Cochrane reviews [10,11]. As a result, brief behavioral interventions are recommended to address the need for cost-effective and timesaving interventions for smokers [12]. In 2013, Lin et al. reported that their pilot randomized controlled trial in Guangzhou, China showed that a 30-second smoking cessation intervention by a physician was an effective way to encourage smokers to quit; the 12-month continuous abstinence rate was 14.9%, compared with 3.8% in the control group. These results suggest that a very brief intervention can achieve a measurable effect in China mainland [13,14].

For smokers who have no intention to quit, smoking-reduction interventions may be a therapeutic choice [15,16]. The common definition of successful smoking reduction is a self-reported reduction of daily cigarette consumption by 50% or more compared with baseline [17]. However, smoking-reduction treatment has been highly controversial in the past [18,19]. The main concerns and uncertainties regarding this approach were that (a) a short-term reduction may not be maintained for long periods [20]; (b) smoking reduction does not necessarily imply harm reduction [21-23]; and (c) future attempts to quit smoking may be undermined by short-term reductions in daily cigarette consumption [20]. However, according to a meta-analysis by Asfar et al., pharmacological combined with smoking-reduction interventions significantly increased long-term smoking cessation rates by factors of 2.14 [19]. Recently, a randomized controlled trial by Chan et al. also supported this conclusion [24]. It has been reported that a smoking-reduction approach may be more likely to be adopted by a broader range of smokers than traditional smoking-cessation interventions [25]. However, limited evidence exists about the effectiveness of behavioral smoking-reduction randomized controlled trials for smokers who have no intention to quit. Glasgow et al. implemented an individual behavioral smoking-reduction intervention for smokers who were not interested in quitting smoking, and the results favored the intervention but did not reach statistical significance [26]. To our knowledge, no previous study has investigated whether a very brief smoking-reduction intervention can increase quitting rates in China; whether this approach is feasible and effective for increasing long-term quit rates among smokers who have no intention to quit remains unclear.

Brief interventions are needed to provide cost-effective and timesaving treatments for tobacco dependence, particularly in developing countries like China. The protocol described here is designed to fit the real life conditions of China mainland. Smoking information should be routinely collected from outpatients in clinics; this interaction provides a good opportunity for doctors to persuade outpatients and their companions to quit smoking. A very brief (i.e., approximately one-minute) smoking-reduction intervention will be proposed to smokers who have no intention to quit. All smokers receiving such intervention will be asked to bear in mind that an attempt to reduce smoking is an intermediate step before complete cessation. During follow-up interviews, if smokers have already reduced their tobacco consumption, they will be encouraged to quit smoking during follow-up interviews. This very brief, active and minimal cost individual smoking reduction intervention will provide strong evidence for a new approach for treating tobacco dependence in China mainland and elsewhere.