Cognitive dissonance-based counseling for reduction in nicotine dependence: A two-arm randomized controlled trial among cigarette smokers

Introduction: Tobacco dependence is a chronic condition often requiring structured behavioral interventions. Conventional tobacco cessation counseling in dental settings largely relies on health education, which may not lead to sustained behavioral change. Cognitive dissonance (CD)-based strategies, which emphasize inconsistencies between beliefs and behaviors, may enhance motivation to quit. Materials and Methods: A two-arm, parallel-group randomized controlled trial was conducted among 128 current cigarette smokers aged 18–45 years attending two tertiary oral health care facilities. Participants were randomly allocated (1:1) to receive either standard 5A’s counseling (control) or the same counseling combined with a CD-based intervention. The CD intervention required participants to publicly advocate against smoking and highlight the benefits of quitting at each follow-up. Nicotine dependence was assessed using the Fagerström test for nicotine dependence (FTND) at baseline and 6 months, while gingival inflammation was measured using the gingival bleeding index (GBI) at baseline, 3 months, and 6 months. Results: Baseline characteristics were comparable between groups. At 6 months, the CD group showed significantly lower FTND scores than the control group (3.04 ± 1.90 versus 4.38 ± 1.25; P < 0.001) and greater dependence reduction (−2.01 versus −0.65; P < 0.001). GBI scores were significantly lower in the CD group at 3 and 6 months ( P < 0.05). Participants in the test arm demonstrated significantly lower FTND scores at 6 months compared with the control group (adjusted mean difference = –1.42; 95% confidence interval (CI): −2.01 to −0.83; P < 0.001). Sensitivity analysis using multiple imputation yielded consistent estimates. Conclusion: Integrating CD induction into standard counseling was associated with greater reductions in nicotine dependence and gingival inflammation than counseling alone. While abstinence outcomes were not assessed, the findings highlight the potential of behaviorally driven interventions to promote gradual reductions in tobacco dependence.