NRT to reduce and eventually quit smoking: does it work?

The package labeling recommendations and normal practice for use of nicotine replacement therapy (NRT, i.e. nicotine patch, gum etc) involves the smoker in picking a day when they will abruptly stop smoking, and start using the NRT as a substitute for smoking. However, over recent years product labeling in some countries (e.g. Great Britain) have allowed some of these products to be used to help the smoker initially reduce their tobacco consumption gradually before eventually quitting. This method has been called, “nicotine assisted reduction to stop”.

Earlier this year Dr David Moore and colleague at the University of Birmingham published a review of all randomized trials comparing NRT with other interventions in smokers declaring an interest in cutting down their cigarette consumption, but no intention to quit abruptly. The primary outcome examined in the review was 6 months of sustained abstinence from tobacco, and they compared the proportion achieving that using NRT with the proportion achieving that outcome when using a comparative intervention (placebo NRT). Note that all of the studies were conducted “double blind”, meaning that neither the smoker nor the researchers were who received NRT and who received placebo NRT until the end of the studies.

The study found 7 trials comparing NRT with placebo NRT. Most of the trials involved about 6 clinic visits. And allowed use of the NRT or placebo for around 12 months, with follow-up typically extending 3-12 more months. The participants in these studies were typically very heavy smokers, averaging over 25 cigarettes per day.

In the final analysis of all the trials, there were around a thousand smokers allocated to NRT and a similar number allocated to placebo NRT. 7% of those using NRT achieved 6 months sustained tobacco abstinence compared with 3 % of those using placebo NRT. All of the other outcomes were also better for the NRT group. For example, 22% of those using NRT had reduced their cigarette consumption by at least 50% at the end of the studies, as compared with 16% of those allocated to use placebo NRT.

There was little evidence to suggest that using NRT while continuing to smoke is dangerous (over and above the dangers of smoking). 4 people died who had used NRT, and 4 died who had used placebo. No other serious adverse events were more likely in the NRT condition. The only symptom found to be more common among those using NRT was nausea, with 9% experiencing nausea who had used NRT, compared to 5% who had used placebo. Very few people discontinued use of either active or placebo NRT because of adverse events ( <2% of each).

So what does this mean? On the one hand it is rather impressive that when you take a large group of smokers who say they are interested in reducing their consumption but are not interested in quitting, and give them NRT gum or inhaler to use for a long period of time, that in fact a significant (but small) proportion actually quit smoking (7%) and a larger proportion (22%) manage to sustain reduced smoking.

On the other hand, there were some characteristics of most of these research studies that make the situation quite different from the “real world” situation of smokers purchasing NRT for “reduce to quit” on their own. One difference is that in these studies the participants were provided with 6 visits including brief counseling to continue reducing their consumption. In the real world that is frequently unavailable (although it could be provided by networks of clinics, and telephone quitlines). In addition, because they were participating in placebo-controlled research studies, all of the participants were given their NRT for free. I understand the good reasons why the research has to be carried out this way, but I suspect it may have a relatively large influence on smoker behavior. I suspect that a much lower proportion of smokers would continue paying out of pocket for BOTH cigarettes and NRT for months and months, particularly if they had no intention of quitting (which implies that the double paying would continue forever).

So for me the message is that if you are a smoker who is not ready to quit abruptly and use NRT in the traditional way, then NRT can help you reduce your cigarette consumption gradually, and by doing this you are more likely to succeed in quitting in the long term. Importantly, the evidence suggests that dual use of cigarettes and nicotine gum or inhaler is not dangerous in terms of nicotine overdose.

Given that we know it is so easy to go back to regular smoking after a brief period of abstinence, I’d recommend that anyone thinking of following this gradual reduction program should have a clear plan and intention to quit smoking completely by a certain date, and that date should not be too far in the future (a month is OK, but 9 months is way too long for most people to persist with dual use towards quitting).

I’d also recommend that those using NRT this way really try to maximize their NRT use and minimize cigarette smoking as early as possible. That way they are more likely to learn to enjoy the NRT and get used to using it as their source for nicotine. Using minimal NRT only in places where you can’t smoke, is more likely to continue the use of cigarettes as the primary source for nicotine.

I’d be interested to hear comments from anyone who has used NRT, or any other methods, to gradually reduce their cigarette consumption. It would also be useful for readers to hear from the experiences of others. Have you tried gradual cigarette reduction, and how did it go?

The published paper by Dr Moore and colleagues can be accessed in full for free at:
http://www.bmj.com/cgi/content/full/338/apr02_3/b1024

Labels: cessation, cigarette smoking, David Moore, jonathan foulds, NRT, smoking reduction

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