Despite tobacco control interventions, the incidence of quitting among US adult smokers has not increased in the last decade. One new method to increase quit attempts is to have smokers reduce their cigs/day. We and others have shown that reduction aided by NRT can increase quit attempts and later abstinence among smokers not ready to quit. Because half of smokers are reluctant to use NRT for a non-cessation reason, we now propose to test whether reduction not aided by NRT can be effective. Another new method to increase quit attempts is motivational counseling. Although some studies have found "motivational interviewing" prompts quit attempts, this treatment is intensive (median time = 1.7 hours) and thus not practical in many settings. We previously found implementation of the USPHS Guidelines 5 Rs motivational intervention via three 15 min phone calls can provide a large increase in quitting (OR = 6.3). However, that study employed a no treatment control group~ thus, we propose to test for efficacy using a more clinically-relevant usual care control condition. We will proactively call adult, daily smokers to recruit 850 smokers who do not plan to quit in the next month and randomize them to a) reduction counseling without the aid of NRT, b) counseling guided by the USPHS 5 R's, or c) usual care. The first two conditions will be delivered via brief counseling calls at study onset and then 2 and 4 weeks later (total = 35 min). The usual care condition will consist of a brief (<5 min) "2 As" intervention and three newsletters providing information on quitting sent at these same times. Our major hypothesis is that the incidence of quit attempts over the 6 months of the study will be greater in both the reduction and the 5 Rs conditions than in the usual care condition. A secondary hypothesis is that the increase in quit attempts will lead to increased abstinence. Another secondary hypothesis is that beneficial effects of both treatments will be mediated by increases in self-efficacy and intentions to quit. A final hypothesis is that decreases in cigs/day and nicotine dependence will mediate the efficacy of the reduction treatment but not the 5 Rs treatment and, conversely, that a shift in decisional balance will mediate the efficacy of the 5 Rs treatment but not of the reduction treatment. If our two interventions are effective, this would encourage quitlines, healthcare organizations and clinicians to offer these time-limited interventions to ambivalent smokers. Also, having an action-oriented intervention (reduction) and a cognitive-oriented intervention (5 Rs) could increase the acceptability of these interventions to different types of smokers. Finally, prior studies have been interpreted to indicate that reducing cigs/day will increase later quitting~ however, all prior studies that have shown this included NRT to aid reduction~ thus, it may be that pretreatment, not reduction is the cause of any increase quitting in prior studies. A study showing that reduction without the aid of NRT increases later quitting would be the first direct test to indicate reduction per se aids later quitting.
New methods to prompt smokers to quit could have a significant public health impact. In a prior study, we found that, helping such smokers to reduce the number of cigarettes/day by counseling plus nicotine replacement therapy (NRT), or motivating them with brief discussions over the phone, both dramatically increased later quitting compared to no treatment. We now propose to re-test these treatments for three reasons: a) because most smokers are not willing to use NRT, we wish to see if reduction without using NRT is effective, b) we wish to test if our reduction and motivational treatments are better than current usual care and c) we wished to conduct a more rigorous experimental test.