By Ellen Feldman, MD

Altru Health System, Grand Forks, ND

Dr. Feldman reports no financial relationships relevant to this field of study.

SYNOPSIS: A one-minute intervention giving facts about the health impact of smoking was presented to 787 men waiting to be seen in Hong Kong emergency rooms. At a six-month follow-up, investigators found a significantly higher abstinence rate in the intervention group.

SOURCE: Li HCW, et al. Effectiveness of a brief, self-determination intervention for smoking cessation (immediate or progressive) among people attending emergency departments: A randomised controlled trial. Tobacco Induced Diseases 2018;16:870. doi:10.18332/tid/84430.

In the time of COVID-19, it seems difficult to focus on any other public health problem. Yet, smoking and tobacco use continue to represent major health morbidity and mortality risks worldwide, causing more than 7 million deaths each year.1 Li et al noted that previous research indicates many patients are not fully motivated to quit smoking, but that many smokers report a desire to reduce the number of cigarettes smoked. The group postulated an intervention following the principles of self-determination theory would be useful in motivating tobacco abstinence. Specifically, this decision-making framework encourages development of intrinsic motivation, autonomy, and personal responsibility.2 When applied to the problem of tobacco use, self-determination theory allows patients more personal decision-making and responsibility in arriving at a smoking cessation timeline and designing a “quit” program.

To test this theory, Li et al engaged healthcare professionals to recruit smokers who presented to four different Hong Kong emergency departments (EDs). Eligible adults were randomized to either an intervention or a control group. The control group received a smoking cessation pamphlet. The intervention group was given brief, direct advice following the AWARD model: Ask (about smoking history), Warn (about dangers), Advise (to quit), Refer (to smoking cessation hotline), and Do again.3 Of the 4,228 eligible smokers approached, 1,517 agreed to participate. Follow-up occurred at one, three, six, and 12 months with biochemical validation of smoking status at six months as the primary outcome. Other outcomes included biochemical validation of smoking status at month 12 and self-reported reduction in tobacco use by at least 50% at months 6 and 12.

In total, 787 persons were randomized to the intervention group and 784 to the control group. In the intervention group, 6.7% had biochemical validation of abstinence from tobacco at six months, while only 2.8% of those in the control group had the same. This was a statistically significant difference. However, when looking at self-reported reduction in tobacco use between the two groups, no statistically significant difference is noted. At the 12-month follow-up, results remained fairly consistent with results from the six-month mark. The results from this study imply that a brief intervention delivered to a “captive” audience (patients waiting at an ED) may be effective in motivating some individuals to stop smoking. It is notable that about 64% of eligible patients declined to be part of the study; the 35.9% who did agree to participate may represent a group with some bias toward smoking cessation. However, as the full group of participants was randomized, this bias should not influence results. Perhaps “less is more,” and the length of time spent in an intervention may be unrelated to outcomes.

It is interesting to speculate that some of the relative success of this intervention may be related to delivering the message while patients were waiting in an ED. Although patients with life-threatening, acute illnesses were not eligible for the study, visiting an ED even for a less urgent reason may raise a person’s awareness of personal vulnerability and increase motivation for adopting healthier habits. It is difficult to know what to make of the nonsignificant findings regarding reduction in tobacco use by more than 50%. In the future, researchers may want to understand this aspect in more depth and develop a method of external validation. Li et al stated the relative success of the intervention is based on delivering a brief, factual message and then offering patients autonomy regarding action and follow-up. This follows the self-determination theory, a decision-making and motivation model. Follow-up studies are needed to determine generalizability. Still, in the interim, this quick intervention and the underlying principle is suitable for front-line clinician implementation. Considering that stopping smoking may be helpful in mitigating the course of an upper respiratory infection associated with the coronavirus, this message may carry even more relevance for the immediate future.


  1. Centers for Disease Control and Prevention. Smoking and Tobacco Use. Fast facts. Nov. 15, 2019.
  2. Center for Self-Determination Theory. Overview.
  3. Suen YN, et al. Brief advice and active referral for smoking cessation services among community smokers: A study protocol for randomized controlled trial. BMC Public Health 2016;16:387.