Evid Based Nurs doi:10.1136/ebn.2011-100224
  • Health promotion
  • Randomised controlled trial

In smokers not willing to quit, counselling on smoking reduction plus free nicotine replacement therapy, compared with one-off cessation advice, increases the proportion achieving abstinence or reduction in smoking rate at 6 months

  1. Roberta Heale
  1. School of Nursing, Laurentian University, Sudbury, Canada
  1. Correspondence to Roberta Heale
    School of Nursing, Laurentian University, Ramsey Lake Road, Sudbury, Ontario P3E2C6, Canada; rheale{at}

Commentary on: [CrossRef][Medline][Web of Science]Google Scholar

Implications for practice and research

  • Counselling for smoking reduction along with free nicotine replacement therapy (NRT) are effective nursing interventions in reducing cigarette consumption and facilitating smoking cessation with the person who is not motivated to quit.

  • Counselling about adherence to NRT may not be effective, however, further research about this intervention is warranted.


Smoking rates have decreased but remain a global health problem. Intervention with smokers, such as the 5A's (ask, advise, assess, assist, arrange), has traditionally been dedicated to the person who wants to quit smoking.1 This study adds to the growing research that supports intervention with smokers who do not want to quit. The researchers sought to determine the effectiveness of smoking reduction counselling along with free NRT in reducing the daily cigarette consumption of smokers who did not want to quit. They also explored the effect of counselling related to adherence to NRT.


A total of 1154 subjects were recruited through the local media or contacted as previous research subjects who had failed to quit smoking. Major inclusion criteria were age of 18 years or older, smoked at least two cigarettes per day, had no intention to quit in the near future but wanted to reduce smoking, had no contraindications to NRT and were not currently on a smoking cessation aid.

Subjects were randomised to one of two intervention groups or a control group. The first intervention group, A1, with 479 subjects, received individual counselling in smoking reduction, counselling about adherence to nicotine replacement therapy (ADIN) and were given a 1 week, free supply of NRT. The subjects in A1 were seen again at 1 week where they were given further counselling in smoking reduction, ADIN, and a 3 week supply of free NRT. At week 4, the process for week 1 was repeated and the subjects were given an additional 4 weeks of NRT.

The second intervention group, A2, with 449 subjects received all the same treatment as A1 except that they were not counselled about adherence to NRT at any of the visits. The control group with 226 subjects received one-time counselling about the health hazards of smoking and the importance of smoking cessation.

The subjects in the intervention groups (A1 and A2) were tested for their exhaled carbon monoxide (CO) level and checked for their NRT usage at week 1 and again at week 4. If a subject in either intervention group indicated that they had stopped smoking in the past 7 days during their week 1 or week 4 visit, urine cotinine levels were checked.

Subjects in the intervention groups (A1 and A2) were contacted at 3 months and detailed information on NRT use from 4 to 8 weeks was collected. All groups, including the control group, were contacted at 6 months by a research assistant who was blind as to the subject's group assignment. Detailed information was obtained about smoking status, nicotine dependency, quit attempts, the cessation methods used and psychological factors. All self-reported quitters and reducers were invited to complete biochemical testing for validation.

The two intervention groups (A1 and A2) were combined and compared with the control group to determine the effectiveness of smoking reduction counselling and free NRT in reducing daily consumption of cigarettes. A1 and A2 were compared to determine the effectiveness of counselling about adherence to NRT. Rates of tobacco abstinence, reduction and adherence between groups were compared. In addition, there was a comparison of rates of reduction in CO levels from baseline to 6 months for subjects who had reduced smoking and who had validated CO levels. Subject's baseline characteristics were analysed. Subjects who did not follow-up were treated as smokers who had not reduced smoking and were non-adherent to NRT in the analysis.


There was a statistically significant difference between the intervention and control groups in the self-reported quit rate at 6 months, which was validated with biochemical testing (CO and urine cotinine testing). There was no difference in the adherence rates to NRT between groups A1 and A2.


Recruitment included, in part, previous research subjects who had not quit smoking. There may be a difference in motivation between these subjects compared with those who had not been previous test subjects. The number of cigarettes smoked per day before the study may have had an effect on the results. This variable should have been more clearly reviewed in the analysis. This study confirms previous similar work but with a larger sample and analysis that included both self-reporting as well as biochemical testing for validation. The study is important in supporting direct interventions with smokers who do not want to quit.


  • Competing interests None.


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