This randomized trial tested a novel strategy for cessation induction among smokers unmotivated to quit (ie, whether brief periods of NT sampling during a PQA acts as a catalyst for quitting). This intervention increased the likelihood of quit attempts and the periods of abstinence during the trial but did not increase abstinence at the 6-month final follow-up assessment. Proxy measures of readiness to quit tended to favor the PQA+NT group, providing evidence that NT sampling operated through the hypothesized pathways. The rates of quit attempts and 7-day point prevalence abstinence with the PQA+NT strategy met or exceeded rates associated with existing options for cessation induction, such as motivational interviewing,12,39
physician-delivered brief advice,40
and smoking reduction.41,42
Our results suggest that brief NT sampling during a PQA is an efficacious intervention to motivate smokers who do not want to quit to successfully initiate the cessation process.
Many smokers are nonresponsive to motivational interventions such as physician-delivered brief advice.43
For smokers who do not respond to cognitively based interventions, an action-oriented strategy such as PQA+NT could be a viable treatment option that gradually introduces the smoker toward quitting. The use of NT for a PQA could occur in an over-the-counter setting without physician involvement; however, it is likely that explanation of the PQA concept and NT sampling by a physician would increase uptake and enhance outcomes.
The NT sampling intervention produced statistically and clinically significant increases in quit attempts, but replication of these findings should focus on abstinence. Methods to enhance abstinence outcomes could include longer duration of NT sampling, NT sampling from a menu of products, or instructions to increase the amount of product to use. As research in this area develops, further consideration should be given to additional mechanisms of change (eg, coping strategies), moderators of treatment effect (eg, prior quitting history), and direct comparison with existing cessation induction strategies.
The PQA intervention seemed to be beneficial, which likely led to the outcomes of the PQA+NT intervention being more modest than if no intervention control group had been used. The rates of quit attempts and cessation in the PQA group were substantially higher than would be expected based on national norms5
(ie, at 6 months, 34% vs 20% had made a quit attempt, and 14% vs 2% were abstinent). Although we know of no experimental test of the efficacy of PQAs to prompt subsequent quitting, evaluations of the Great American Smokeout44
and similar mass media campaigns9
suggest that PQAs could be effective. Future research on PQAs per se is indicated.
Study strengths include a novel treatment approach (tested among a group of proactively recruited smokers nationwide), a unique method of identifying cessation-resistant smokers, and strong rates of study retention. Study limitations include the absence of a control group without treatment, which prevented a test on PQAs per se. A nonintervention control group was not included because the research question focused on NT sampling in the context of a PQA, rendering PQA alone as the most apt control. Some might view the absence of a placebo control as another weakness. However, our primary aim was to determine if provision of NT sampling promotes quit attempts, not whether any such effect was pharmacologically mediated. An additional limitation was the potential lack of representativeness of the study sample, which was 88% non-Hispanic white, a likely consequence of the online recruitment strategy. However, although a potentially skewed sample recruited through online methods may affect external validity, this would not affect the internal validity of a randomized trial.45
Finally, the study would have been strengthened by inclusion of biochemical verification of the secondary end point of abstinence.
In summary, providing brief NT sampling to smokers who do not want to quit, when used within a behavioral exercise of a PQA, is efficacious to motivate unmotivated smokers toward quitting. Considering the stagnant incidence of quit attempts in the past decade, this novel and easy-to-use cessation induction strategy holds promise for translation to primary care settings.