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• Reduction as Prelude to Cessation
  John R Hughes
  Published on: 7 September 2006

• Published on: 7 September 2006

  Reduction as Prelude to Cessation

  • John R Hughes, Professor
  • Other Contributors:
    • Matthew Carpenter

  The recent article by Gilpin, et al.,[1] reported the major initial impact of California’s tobacco control efforts was to initially reduce cigs/day among continuing smokers and this was followed by an increase in quitting.[1] We would like to make three comments on this paper.

  First, this study was one of the first to decompose the effects of tobacco control into effects on initiation, cessation and reducti...

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  The recent article by Gilpin, et al.,[1] reported the major initial impact of California’s tobacco control efforts was to initially reduce cigs/day among continuing smokers and this was followed by an increase in quitting.[1] We would like to make three comments on this paper.

  First, this study was one of the first to decompose the effects of tobacco control into effects on initiation, cessation and reduction. Such analyses are crucial to understanding how tobacco control works. Second, decreased tobacco sales data appeared to be an early indicator of later declines in prevalence; thus, when tobacco control programs are pressed to show changes in the first few years, sales data may be the most sensitive measure to document progress or the lack thereof.

  Third, although the authors did not state that reduction in cigs/day caused later changes in quitting, some readers could interpret their data to indicate this. An alternate explanation is that reduction in cigs/day was simply an indicator of other processes such as denormalization of smoking. However, other data suggest reduction may, in fact, cause increased cessation. Our recent review found that among the 19 studies of reducing cigs/day in smokers not trying to quit, 16 found reduction was followed by increased cessation.[2] Importantly, among the 10 randomized controlled trials of using medications or behavioral treatments to induce reduction, 9 found reduction led to increased quitting. Although these studies focused on interventions at the individual level, it may be that reduction in cigs/day achieved by tobacco policies, taxes, community interventions, etc. also lead to later cessation. Gilpin, et al., [1] hypothesized a mechanism by which reduction might lead to cessation; i.e., reduced cigs/day may lead to decreased dependence. Although this is highly feasible, surprisingly, our review could not find any studies that have tested this. Other possible mechanisms include reduction increases self-efficacy or disrupts the association of smoking with specific environmental cues.

  If reduction leads to cessation, then when treatment programs observe that some relapsed smokers return to lower cigs/day than prior to attempting to quit, they should implement treatments to maintain this reduction. In fact, the Lung Health Study undertook such a strategy (via continued use of medication) in many relapsed smokers[3] and reported one of the highest rates of long-term cessation in the literature.[4]

  Reference List

  1. Gilpin EA, Messer K, White MW et al. What contributed to the major decline in per capita cigarette consumption during California's comprehensive tobacco control programme? Tob Control, 2006;15:308-316.

  2. Hughes JR, Carpenter MJ Does smoking reduction increase future cessation and decrease disease risk? A qualitative review. Nicotine Tob Res, in press

  3. Hughes JR, Lindgren PG, Connett JE et al. Reduction of smoking in the Lung Health Study. Nicotine Tob Res, 2004;6:275-280.

  4. Anthonisen NR, Connett JE, Kiley JP et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV. JAMA, 1994;272:1497-1505.

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  Conflict of Interest:
  None declared.

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