Efficacy of Motivational Interviewing and Brief Interventions on tobacco use among healthy adults: A systematic review of randomized controlled trials

Abstract Objective. To assess the effectiveness of a brief intervention and motivational interviewing in reducing the use of different tobacco-related products in adults Methods. For this systematic review, PubMed, Web of Science, and PsychINFO databases were electronically searched for randomized controlled trials on the effect of a brief intervention and / or motivational interview on tobacco reduction among healthy adults published between January 1, 2011 to January 1, 2021. Data from eligible studies were extracted and analyzed. CONSORT guidelines were used to assess the quality of the studies by two reviewers for the included studies. The titles and abstracts of the search results were screened and reviewed by two independent reviewers for eligibility criteria per the inclusion and exclusion criteria. Cochrane review criteria were used to assess the risk of bias in included studies. Results. A total of 12 studies were included in the final data extraction of 1406 studies. The brief intervention and motivational interviewing showed varied effects on tobacco use reduction among adults at different follow-ups. Seven of the 12 studies (58.3%) reported a beneficial impact on reducing tobacco use. Pieces of evidence on biochemical estimation on tobacco reduction are limited compared to self-reports, and varied results on quitting and tobacco cessation with different follow-ups. Conclusion. The current evidence supports the effectiveness of a brief intervention and motivational interviewing to quit tobacco use. Still, it suggests using more biochemical markers as outcome measures to reach an intervention-specific decision. While more initiatives to train nurses in providing non-pharmacological nursing interventions, including brief interventions, are recommended to help people quit smoking.

were used to assess the risk of bias in included studies. Results. A total of 12 studies were included in the final data extraction of 1406 studies. The brief intervention and motivational interviewing showed varied effects on tobacco use reduction among adults at different follow-ups. Seven of the 12 studies (58.3%) reported a beneficial impact on reducing tobacco use. Pieces of evidence on biochemical estimation on tobacco reduction are limited compared to self-reports, and varied results on quitting and tobacco cessation with different follow-ups. Conclusion. The current evidence supports the effectiveness of a brief intervention and motivational interviewing to quit tobacco use. Still, it suggests using more biochemical markers as outcome measures to reach an intervention-specific decision. While more initiatives to train nurses in providing non-pharmacological nursing interventions, including brief interventions, are recommended to help people quit smoking.

Introduction
T obacco in any form is harmful and affects millions of lives every year. (1) In 2017, 8 million lives were lost due to smoking-related diseases. (2) Tobacco-related deaths are rising even after a decline in tobacco use trends because of the chronic nature of conditions. (3) In 2000, around 33.3% of the global population over 15 years old were current tobacco users. (3) The negative consequences of tobacco use are well known and extend beyond individuals and countries regarding increasing health care expenditure and loss of productive life. (4) The tobacco consumption trend was three times higher in males than females in 2000, which was increased to four times in 2015 and is projected to be five times by 2025. (1,3) Notably, the detrimental effects of tobacco use gravely affected lower socio-economic populations with higher smoking prevalence. (5) However, tobacco use practices are varied and influenced by the locally available tobacco products in the different regions worldwide. (6) Smoking is one of the modifiable risk factors for many life-threatening health problems, including respiratory and cardiovascular health and genitourinary problems. (7) It has been estimated that 50% of smokers who start smoking in adolescence die due to tobacco-related health problems. (8) Thus, an effective measure to control tobacco addiction is paramount. Implementing a wide range of interventions and strengthening tobacco control policy, including taxation, ban on tobacco use in public places, restriction on advertising of tobacco products, and creating smoke-free zones in educational institutions, brought a substantial decline in tobacco use in recent decades. (4) In addition to government initiatives to curb tobacco use, many pharmacological and nonpharmacological approaches are also involved in reducing tobacco-associated mortality and the burden of diseases. (6,9) Earlier studies reported that using a combination of pharmacologic and non-pharmacologic intervention is highly effective in reducing tobacco use. (10)(11)(12) However, non-pharmacological interventions have advantages over pharmacological interventions, including no side effects, long-term behavior changes, (13) knowing the real health hazards of long-term tobacco use, and cost-effective to show higher compliance. (11,12,14) Non-pharmacologic interventions for tobacco cessation include telephone counseling, individual and group counseling, health care provider interventions, exercise programs, and self-help programs. (12) Brief intervention or motivational interview is a brief yet realistic strategy offered to those who have a low motivation to quit. (15) Brief intervention is goal-directed but nondirective communication designed to improve motivation for change in quit behavior by eliciting feedback to plan for change. (12,(16)(17)(18)(19)(20) The terms brief intervention (BI) and motivational interview (MI) are used with a common principle of active engagement of the client in the process of reduced use and teaching alternative coping skills. (21) These interventions are based on the philosophy that the client holds a key role in showing commitment and successful recovery. (22) Brief intervention sometimes follows the principles of the motivational interview to motivate the specific behavior of an individual to reduce or quit substance use. (23) However, these interventions are substantially modified in the delivery approach, format, and content in earlier published work. (12) Brief intervention primarily focuses on present concerns and stressors rather than exploring the historical antecedents of an individual and is conducted by a trained therapist. (20,24) Earlier work on the efficacy of brief intervention reported evidence that brief intervention increases the motivation to quit short-term use. (18,25) However, the evidence on long-term effects of brief interventions is equivocal, with no reduction of tobacco use at three months while higher self-reported abstinence at 1-year post-brief intervention. (26) Conversely, the brief intervention was found to be effective in improving quit rates, prolonging abstinence, and improving self-reported continuous abstinence among smokers at six months (27) and 1-year postintervention (28) in other work. Still, there is a lack of consistent evidence on brief interventions to reduce use or quit tobacco use among the adult population.
Nurses are an essential attribute of the health care system and play a vital role in delivering various interventions. It is natural to expect that nurses with adequate knowledge and skills in the brief intervention will do more to help their patients quit smoking. This meta-analysis will highlight the need for encouragement and opportunities to nurses to receive training on smoking cessation interventions. In addition, this will be insightful for the nurses to understand the significance of a non-pharmacological intervention to quit smoking. Towards this end, training nurses in the brief intervention using motivational interviews may be helpful to smokers and their families. Consequently, this systematic review aims to assess the effectiveness of the brief intervention in reducing tobacco use among adults.

Methods
A literature review was conducted with online databases PubMed, Web of Science, and PsychINFO. A literature search was completed using Boolean operators and truncations for the following key terms: (1) "Brief Intervention, (2) OR Screening and Brief Intervention" "tobacco products" AND (3) "Tobacco OR "tobacco products," (MESH terms are also included in the search). The problem/disease was tobacco use among adults in the experimental group. The primary outcomes of interest were cessation in tobacco use, motivation/readiness to quit, reduction in tobacco quantity, days, abstinence days, quit attempts, and point prevalence measured by self-reported methods or biochemical verification at different intervals.

Selection criteria and data extraction. The inclusion
criteria for the studies included in this review were as follows: (1) the content of the article mainly focused on the provision of brief intervention and/or motivational interview for tobacco use reduction or cessation; (2) the participants were current smokers and adults; (3) the articles were published in peer-reviewed journals within the last ten years; (4) the study method reflected a randomized control trial (RCT). Articles were excluded if they focused primarily on other pharmacologic interventions, included any other substance use, were not designed as an RCT, or had mixed interventions. The search strategy was based on the population, intervention, control, and outcomes (PICO) approach with a PICO question, 'does motivational interviewing and brief interventions helpful in reducing tobacco use in healthy adults?'; where P-Healthy tobacco users, I-Motivational Interview and/or Brief Intervention, C-Usual care or on other interventions and O-Smoking cessation. (29) A total of 1406 articles were included for a title and abstract review; at least two team members discussed discrepancies. 77 articles met the inclusion criteria for a fulltext review, and 12 articles were selected for data extraction. See the PRISMA framework ( Figure  1) that guided the review process. (30)   outcomes assessment refers to whether outcome measurement could have been changed by prior intervention knowledge to participants or team members delivered in work. Selective reporting refers to presenting only findings of interest. An incomplete outcome does not consider attrition while submitting the result. (31) For each study, these components are shown in 'high risk,' 'low risk,' or 'unclear' as written in the published version of the manuscript to decide on bias assessment. In data extraction, two authors assessed each study for bias. The authors discuss the risk bias criteria of the study using a checklist and conclude. The discrepancies were resolved after a discussion with the third author Table 1.
Bias assessment. Cochrane review criteria were used to assess the risk of bias in included studies in the review (Table 1). (31) All studies were evaluated on six evidence-based domains: allocation concealment, random sequence generation, participants and personnel blinding, outcome blinding, incomplete outcome data, and selective reporting. (31) Allocation concealment refers to concealing the information on the randomization process to the subjects. Random sequence generation occurs when study participants are not aware of the random sequence generation process. Blinding of participants and personnel refers to when participants and team members do not know the intervention or control condition to which subjects are assigned. Blinding of

Results
The electronic search produced a total of 3162 articles. 1406 articles were found suitable after removing duplicate records. Abstracts of all articles were reviewed independently by two reviewers. A total of 1262 articles were excluded after careful scrutiny of abstracts. Full-text articles were retrieved for 79, and after reviewing these articles independently, 67 articles were further excluded for a specific reason. After applying the eligibility criteria, 12 articles were included in the present review. The PRISMA flow diagram ( Figure 1) summarizes the study selection and scrutiny process used for the articles. A summary of the selected studies summarized by year of publication, author, setting, type of study, sampling techniques, sample size, eligibility criteria (inclusion and exclusion), intervention, outcomes, strengths and limitations, and any other specific notes to the study.

Study characteristics.
Of the 12 included studies, eight were conducted in the United States, one in Sweden, one in Hong Kong, one in Germany, and one in Spain. All studies used a randomized controlled trials design with one or another trial feature, including allocation concealment and blinding. Of the 12 studies, 3 studies used brief intervention or brief advise, (30,32,35,38,41) 6 studies used motivational interviews, (15,30,33,34,37,40) and one study used brief counseling on harm to self and harm to others (39) and quit immediately award model based on brief intervention approach. Seven of the 12 studies (58.3%) reported a beneficial effect of brief advice or motivational interview on reducing tobacco use ( Table 2).

Motivational Interviewing (MI).
The concept and use of motivational interviewing as an intervention is not new in substance use, (42) smoking reduction, (43) chronic lifestyle disease, (44) health behavior, (45) medication adherence, (46,47) oral health in adolescents, (48) and chronic pain management. (49) The concept was published by Miller & Rollnick and presented as a therapeutic effort to strengthen personal motivation and commitment to a specific goal by eliciting and exploring the individual's reason for a change in behavior with compassion and acceptance. (16) Motivational interviewing (MI) is a patientcentered, directive therapeutic style to improve readiness to change behavior by resolving the ambivalence. (43) MI was found to be an effective method in a series of addictive behaviors. (50) Some research (33) among healthy adult smokers tested multiple interventions revealed a promising effect of motivational interviewing on smoking reduction. However, the study concluded (50) that motivational interviewing and other interventions will produce the most consistent and marked reduction in smoking. A contrasting study (15) used motivational interviewing over health education and brief advice but did not report any change in quit attempts at 6 months. However, the same study reported increased cessation of medication use, motivation, and confidence to quit compared to brief advice, which further indicates the effectiveness of MI in behavior changes to quit smoking. In a study (34) at a Northeastern US State, daily smokers attended brief motivational interviewing and significantly reduced cigarette use. Likewise, motivational interviewing effectively improved quitting smoking among nurses over brief advice in a study conducted in Spain. (30) However, in another work (37) on college tobacco smokers, the use of motivational interviewing over health education (HE) showed no significant reduction in motivation to quit, abstinence, and quit attempts. Likewise, the consistent findings are presented in earlier studies (15,51) that reported no significant advantage of MI on smoking cessation compared to alternative interventions. In a recent work conducted in the Midwest United States, a brief motivational interview showed no improvement in reducing water pipe use (40) ; however, MI was found to improve awareness of risk perceptions, commitment, and confidence to quit waterpipe (WP) smoking.
Furthermore, in a recent meta-analysis, MI reported a modest yet significant beneficial increase in quitting rates in a group that utilized motivational interviewing. Further, findings revealed that longterm motivational interviewing by a primary physician or counselor is more effective in quitting tobacco. However, there is no specific evidence on the duration and number of MI sessions on quitting the behavior. Another meta-analysis (52) reported a greater likelihood of abstinence behavior in the experimental arm comprising adults and adolescents when compared to the comparison group. Still, only a few older interventions and meta-analyses demonstrate the effectiveness of motivational interviewing in smoking cessation. There is evidence that motivational interviewing is less effective in low-motivation patients. (18,53) However, the conclusive evidence to prove the quality and fidelity of MI implementation remains contentious concerning its effectiveness in smoking reduction.
Brief Intervention. Brief intervention or advice for harmful substance use has been practiced for many years. (54) It aims to identify the current and potential problems with substance use and motivate people to change high-risk behavior. (55) Brief intervention is a personalized, supportive and non-judgmental approach to treatment. (55) It is also defined as a verbal 'stop smoking' message loaded with harmful effects of tobacco use. (56) Brief intervention can be used in various methodologies, including unstructured counseling and feedback to formal structured treatment. (57)(58)(59) World Health Organization uses education, simple advice, and brief counseling as alternative types of brief interventions for high-risk individuals with alcohol use disorders. (60) Brief intervention also uses screening and referral services and is therefore called screening, brief intervention, and referral to treatment (SBIRT). (61) Brief therapy can help motivate an individual to change his high-risk behavior at a different stage of behavior change. (62) The stage of change model proposed by Prochaska & DiClemente, helps clinicians tailor a brief intervention to the stage of behavior change and the client's needs. (63) Brief interventions for tobacco use disorders aim to enhance motivation for change and provide evidence-based resources to reduce usage or complete cessation of tobacco products. The 5A's approach (Ask, Advise, Assess, Assist, & Arrange) is an evidence-based approach that helps tobacco users in different settings with motivational strategies in a systematic fashion. (64) In addition, FLAGS-Feedback, Listen, Advice, Goals, Strategies and 'FRAMES'-Feedback, Responsibility, Advice, Menu of options, Empathy, and Self-efficacy, are other frameworks used to deliver brief interventions. (65) The brief intervention is effective in many ways, including cost-effectiveness in terms of time and money, (66) increased abstinence rate and days, (35,67) and early days of discharge, and regular followups (68) . Similarly, a more intensive planned brief advice (>20 minutes) may augment the effect on quit rate and 6-months abstinence compared to minimal brief advice. (69) Additionally, the use of brief components in AWARD [Ask, Warn, Advice, Refer, Do-It Again) model, and cut down to quit: [CDTQ]), reported a higher quit rate in the former group. (35) Furthermore, brief advice in combination with tailored practice was highly effective on 7-days point prevalence and 7-days and 6-months abstinence rate among adult smokers. (38) Brief counseling also reported a significant reduction in quit rate, abstinence phenomenon, improved motivation, and self-efficacy in a regular follow-up in a group of nondaily smokers. (36,39) Conversely, brief therapy showed no significant changes in abstinence rate among adults who underwent immediate and delayed intervention at the family health clinic U.S.-Mexico border, (41) and hence, the efficacy of brief therapy has been questioned in recent years. (70) Further, brief treatment can be helpful for varied kinds of the population, including adolescents, older smokers, smokers with mental illness and co-morbidities, alcohol users, and pregnant women across different racial and ethnic groups. (66,70) However, current or former tobacco smokers who were willing or unwilling to make quit attempts are the most eligible groups to attend the brief intervention. (66)

Discussion
The use of tobacco has innumerable adverse effects on health. The present review aimed to assess the effectiveness of a brief intervention in reducing tobacco use among adults. The review findings indicate that brief intervention alone or combined with Motivational Interviews or Health Education was effective, supported by previous results. (15,52) In contrast, an earlier systematic review documented that motivational interviewing was modestly successful in promoting smoking cessation compared with usual care or brief advice. (25) Conversely, motivation to quit was higher after Brief Advice than MI. (71) Another recent systematic review conducted with 37 studies reported insufficient evidence to show whether MI helps people stop smoking compared with no intervention, as an addition to other types of behavioral support, or compared with different kinds of behavioral support for smoking cessation. (72) Modality and intensity of interventions with followup and primary outcomes were also determining factors for the effectiveness of the studies. In the current review, the intervention modality varied in face-to-face sessions or a combination of face-toface and telephone sessions. Initial sessions were conducted face-to-face, and the follow-up was done over the telephone for most of the study, which is usual with much other previous work. (72) Brief intervention provided through telephone has great significance in the present scenario. Amid the COVID-19 pandemic, when individuals have restricted movement or limited resources available, virtual or phone delivered brief intervention can play a significant role in helping the adults quit smoking or reduce tobacco use. A previous study has documented moderate-certainty evidence of proactive telephone counseling in increasing the quit rates in smokers who seek help from quitlines. (73) The included studies had intervention sessions as little as one brief session (37) to four sessions based on Motivational Interviews. (30) Prior literature suggests that multiple sessions might increase the likelihood of quitting over single-session treatment, but positive outcomes were reported in both cases. (25) However, there is no specific evidence on the duration and number of MI sessions on quitting the behavior. (72) The current review found that the included studies had a follow-up of the intervention ranging from 3 months to 12 months. However, face-to-face or telephone counseling follow-up did not show a significant effect of an intervention. However, reduction of smoking behavior or abstinence was not sustained over time. These findings were supported by a previous work where smoking abstinence averaged 10% at 1 month and around 2% at 3, 6, and 12 months. (71) At present, evidence is unclear on the optimal number of follow-up calls. (25,43) The primary outcomes of the studies were smoking abstinence, reduction in smoking rates, and an increase in motivation to quit. However, outcomes other than cessation may be essential to assess when determining the effects of brief interventions for tobacco use. Hence, different outcomes were self-efficacy, motivation, and changes in depression over the studies. Biological tests to confirm tobacco abstinence provided more reliable findings than self-reported abstinence.
Intervention programs on Smoking cessation, such as brief advice, motivational interviews, or the 5A approach (Ask, Advise, Assess, Assist, and Arrange), are effective among specific populations or specialized clinical settings. (45,74) Professional support and cessation interventions or medications significantly increase the chance of successfully quitting. (3) A systematic review and meta-synthesis explored smokers' perspectives regarding smoking cessation and reported that lack of motivation to quit was one of the significant issues they felt for tobacco cessation. (75) Nonetheless, these non-pharmacological interventions had shown efficacy similar to the pharmacological intervention (74) with additional benefits of cost-effectiveness, competency of the provider, and accessibility to the treatment center.
Tobacco-related deaths and disabilities are increasing around the globe because of the continued use of different kinds of tobacco products. Many earlier studies confirmed the beneficial effect of a brief intervention based on motivational principles to reduce tobacco use. Nurses' role is precise in tobacco cessation to endorse the International Council of Nurses statement to integrate tobacco use prevention and cessation as part of their regular nursing practice. (76) This systematic review indicates the potential benefits of brief intervention, which can be a breakthrough for nurses in tobacco reduction around the globe. However, nursing policymakers should incorporate smoking cessation interventions as a part of standard practice for all the patients. Hence, brief intervention or motivational interviews provide promising results in cessation or reduction of tobacco use which needs to be further supported by evidence.
The present review should be appraised under its many limitations and strengths. Among its strengths is that it provides coverage of randomized controlled trials that included brief intervention and motivational interviewing on smoking and other tobacco use among adults. This review included samples of those with clinical and non-clinical samples using tobacco. The major strength of this review lies in the inclusion of RCT studies that give a clear description of participants' characteristics, methodology, and implemented intervention. Secondly, the risk of bias assessment showed that most studies had low to moderate risk. This review highlights several opportunities for future research, such as brief intervention or motivational interview combined with other adjuncts to improve outcomes and further research integration of these interventions with combination therapies of psychotherapeutic and pharmacological interventions.
In terms of limitations, the heterogenicity of the selected studies did not allow to reach a specific conclusion. Studies included in this review used different brief intervention and motivational interview forms, making it challenging to synthesize the results and suggest a potential use of these interventions in day-to-day practice. Heterogeneity in population also made it challenging to generalize the findings across all people around the globe. Further, studies involved in the review only investigated tobacco cessation among healthy adults may confer unique limitations on the generalizability of results. The authors suggest interpreting and using review findings cautiously due to variations in treatment fidelity and the inclusion of a limited number of studies.

Conclusion.
Over time there have been changes in treatment modalities for tobacco cessation. Preference for non-pharmacological intervention over pharmacological has led the researchers to find supportive evidence. The present review highlights the effectiveness of a brief intervention and motivational interviewing in reducing tobacco use among adults. It also demonstrates that the effects are far-reaching. However, it remains inconclusive which intervention is more effective than the other. Future longitudinal studies or RCTs with direct comparison of different interventions may further refine the evidence-based practice on tobacco cessation among adults.
Funding Sources: None declared. . Design: Single site, parallel-group RCT design. Randomization: Computer-generated random assignment, Imbalanced allocation (2:2:1) for three interventions Inclusion criteria: Adult age 18 years & currently smoking one or more cigarettes per day, able to speak English, have stable reachability, no intention to get pregnant in the next 6 months, not using any medication for smoking cessation, have no cessation plan in the next 7 days and confirm tobacco use on CO≥7 ppm. Exclusion criteria: N/A Intervention and comparators: Motivational interview (MI, n=102) Versus Health education (HE, n =102) Versus Brief advise (BA, n =52)

Primary outcomes:
The health education group significantly shows a higher abstinence rate at 6-month follow-up, Motivational interviews and health education groups showed a more significant increase in reduced medication use, motivation, and confidence to quit over the brief advice group, Health advice was relatively found better to improve motivation than motivational interviewing.
Others: Strengths: Biochemical verification of 7-day smoking point prevalence by saliva testing, use of intensity match comparison design to test the exact effect of MI over health education. Limitations: Self-reported measures to test motivation, desire to quit, quit attempts, and point prevalence, the study was limited to willing to quit smokers, and findings may not be generalizable to unmotivated smokers.
Any other Notes: Follow-up for all three interventions at 3 months and 6 months. Missing data handling using appropriate measures to avoid bias in the study. Inclusion criteria: Nurses who smoke and are ready to participate in the study and nurses work in the hospital irrespective of thinking of quit or not.] Exclusion criteria: N/A.