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Research papers: Aage Tverdal and Kjell Bjartveit Health consequences of reduced daily cigarette consumption Tob Control 2006; 15: 472-480 [Abstract] [Full text] [PDF]

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Reduction increases quitting

John R Hughes   (20 January 2007)

Re: Reduction increases quitting

Kjell Bjartveit, Aage Tverdal, Kjell Bjartveit   (29 January 2007)

Reduction increases quitting 20 January 2007
John R Hughes, MD University of Vermont, USA Send letter to journal: Re: Reduction increases quitting john.hughes{at}uvm.edu John R Hughes	The recent study by Tverdal and Bjartveit (TC 15:472-480, 2006) that found no health benefit from reducing cigarettes had several assets not found in the few prior prospective studies of this topic; e.g. the reducers had reduced by over 50% and several outcomes were measured. I would, however, like to make two comments. First, one asset of the study was the examination of "sustained reducers;" i.e., those who reported reduction at two consecutive examination. Although this estimation of sustained reduction is superior to that in prior studies, the question at each follow-up did not appear to ask about smoking since the last follow-up but rather asked about smoking at the current time; thus, in actuality, it is unknown what the rate of smoking really was between follow-ups in "sustained reducers." As a result, there is still the possibility that these results are false positives. Having said that, I do believe the burden of proof is on those who believe reduction is helpful to provide more rigorous tests. Second, the concluding sentence of the abstract states advising reduction may "give people false expectations." While this may be true to some extent, advising reduction does not appear to undermine motivation to quit but actually increases motivation to quit. Dr Carpenter and I published a review paper of 19 studies (that did not come out until after this current study was submitted). None of these studies suggested reduction undermined motivation to stop smoking. Instead, 16 of the 19 found smoking reduction increased the probability of future cessation. (NTR 8:739-749, 2006). Thus, I believe smoking reduction can be beneficial to smokers if they see reduction not as an end itself but as way to quitting. In fact, surveys suggest this is exactly how the large majority of smokers see reduction (Hughes et al, NTR, in press)
Re: Reduction increases quitting 29 January 2007
Kjell Bjartveit, Director emeritus National Health Screening Service, Aage Tverdal, Kjell Bjartveit Send letter to journal: Re: Re: Reduction increases quitting kjell.bjartveit{at}chello.no Kjell Bjartveit, et al.	Reduction as a permanent solution may give people false expectations Thanks to Dr. John R Hughes for his interesting remarks of 20 January 2007 to our article (TC 15:472-480). We have the following comments: 1. Dr. Hughes states that our main finding (no health benefit from reducing cigarettes) has not been found in the few prior prospective studies of this topic. This is not correct. Based on a large study population in Copenhagen, Dr. Nina S Godtfredsen and co-workers have reported the same results in a series of publications, references given in our article. Dr Hughes’ remarks imply that there may be other prospective studies that give other results. We have not been able to find other prospective studies that take up this problem. 2. Our article reports on results from three examinations; for the majority of participants the interval between the examinations was five years. A subgroup of the study population was nominated ‘sustained reducers’. They were heavy cigarette smokers at the first examination, had reduced their daily cigarette consumption by at least 50 % at the second examination, and had remained as ‘reducers’ at the third examination. Their mean consumption at the three examinations was 23.6 – 10.0 – 10.4 cigarettes per day (table 6 in our article). Dr Hughes states that “the question at each follow-up did not ask about smoking since the last follow-up”. This is correct, and we agree with Dr Hughes that it is unknown what the rate of smoking really was between follow-ups in sustained reducers. The sustained reducers had, however, a mean daily consumption that was almost the same at the second and third examination, and in our opinion, the most reasonable explanation is that their daily cigarette consumption had stabilised at a consumption level which actually was at least 50% lower than at the first examination. We also underline that at the second examination, reducers had a serum thiocyanate level that was lower than in heavy smokers, and close to the serum thiocyanate level in moderate smokers (table 3 in our article). 3. Dr Hughes states that reduction actually increases motivation to quit. In our paper, we state explicitly:”Undoubtedly, reduction in consumption may have a place as a temporary measure in systematic smoking cessation”. Our conclusion that advising reduction may give people false expectations, refer to reduction as a permanent solution. We think that the results of our study and of those of the Copenhagen Study, with study populations of more than 70 000 persons together, give a sound basis for this conclusion. Age Tverdal, Professor Norwegian Institute of Public Health, Oslo Kjell Bjartveit Director Emeritus National Health Screening Service Oslo