Cutting down can be the first step to quitting
What advice should be offered to patients who say that they are unready or unable to quit smoking? Does advice to cut down help to engage with hardened smokers and act as a step towards a quit attempt, or does it undermine the importance of quitting? Does cutting down itself produce any health benefits?
To answer these questions, the Cochrane Tobacco Addiction Group has published a systematic review of interventions to reduce harm from smoking.
The review included 13 randomised or quasi-randomised controlled trials, of which eight looked at the effectiveness of nicotine replacement therapy (NRT) compared with placebo as a means of reducing the number of cigarettes smoked daily.
Combined analysis of these eight trials, covering 3,273 smokers, found that NRT doubled the odds of a smoker reducing the number of cigarettes smoked daily by at least half (OR 2.02, 95% CI 1.55-2.62). However, this was not associated with a significant reduction in levels of carbon monoxide or cotinine (markers of tobacco smoke intake). Use of NRT to cut down almost doubled the rate of subsequent quitting (OR 1.90, 95% CI 1.46-2.47).
The authors conclude that the health benefits of cutting down smoking are uncertain. It does offer, however, a possible alternative quitting strategy, whereby smokers unwilling or unable to stop immediately may cut down first, then quit. This is the basis for the licensing of certain NRT products for a ‘cut down to stop' indication.
In the past, there was concern that using NRT while still smoking might result in increased nicotine intake. Studies suggest that this does not occur, and that medicinal nicotine has a low potential for adverse effects.
There can be no doubt that the best way to avoid the health risks from smoking is to stop completely. Even low levels of smoking are extremely dangerous. However, some smokers feel that quitting is just too big a step. For these patients, cutting down might be used as a short-term strategy to encourage quitting.Reviewer
Dr Kevin Lewis
Former GP, Clinical Director of Smoking Cessation, Shropshire County Primary Care Trust