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Cessation attempts could be increased and smoking-related harm reduced by providing indication for NRT that includes concurrent use while reducing cigarette consumption.

A number of studies have been conducted examining the use of NRT as an aid to smoking reduction among smokers who are not yet willing to make a quit attempt. The available data suggest that NRT is an effective intervention in achieving sustained smoking reduction for smokers who have no intention or are unable to attempt an abrupt quit (Moore et al., 2009). Furthermore, available data suggest that NRT-assisted reduction can in fact lead to complete cessation, even among smokers who initially express no interest in quitting (Hughes & Carpenter, 2006). For example, a recent Cochrane Review examined 150 trials that compared any type of NRT compared to placebo or a non-NRT control group and concluded that NRTs increase the rate of quitting by 50 to 70% (Stead et al., 2012). In addition, effectiveness was independent of additional support suggesting that increasing such support will not increase the likelihood of tobacco abstinence.

In a 2005 review of the topic of concurrent NRT and tobacco use, Action on Smoking and Health (ASH) suggested that:

  • Nicotine replacement helps smokers unwilling or unable to stop achieve sustained reduction in cigarette consumption;
  • This reduction is accompanied by a reduction in smoke intake;
  • There is minimal risk of significant adverse reactions to smoking concurrently with nicotine replacement;
  • Smoking reduction using NRT increases motivation to stop smoking; and
  • Smoking reduction using NRT increases subsequent cessation.

ASH point out that several European countries now have approved indications for use of NRT to support smoking reduction, and that this practice appears to be cost-effective as well.

More recently an opinion piece in the New England Journal of Medicine by leaders in the tobacco field advised clinicians to tell patients who smoke and are not willing to make a quit attempt that using NRTs may help them reduce and ultimately end their combustible use (Fiore, Schroeder, and Baker, 2014). This recommendation is evidence-based as smoking reduction using NRT and increased likelihood of quitting has been demonstrated previously (Carpenter et al., 2004).

The US Public Health Service clinical practice guideline (Fiore et al., 2008) reported that the use of NRT among patients not currently willing to make a quit attempt (but willing to reduce smoking) more than doubled the likelihood that a smoker would be abstinent at 12 months, despite the smoker's unwillingness to make a quit attempt at the time of initial assessment. While the Guideline Panel declined to recommend this intervention for broader clinical use, they did not question its fundamental safety or efficacy but did raise issues about the study designs used and that there were no data indicating that NRT-assisted smoking reduction was superior to cognitive-behavioral interventions to boost quitting. Additionally, recent reviews note the importance of optimizing NRT efficacy using novel approaches such as pre-quit NRT use (Carpenter et al., 2013).

Overall, further research may be needed for this recommendation to be more universally accepted, but it seems quite promising as another approach to both smokers who are not yet ready to quit, and as a way to recycle smokers following relapse.  The potential of this practice for harm reduction, though, is yet unclear.

Action on Smoking and Health (ASH) 2005. Nicotine Assisted Reduction to Stop (NARS). Guidance for health professionals on this new indication for nicotine replacement therapy.

Carpenter MJ, Hughes JR, Solomon LJ, Callas PW. Both smoking reduction with nicotine replacement therapy and motivational advice increase future cessation among smokers unmotivated to quit. J Consult Clin Psychol. 2004; 72: 371-381.

Carpenter MJ, Jardin BF, Burris JL, Mathew AR, Schnoll RA, Rigotti NA, Cummings KM. Clinical strategies to enhance the efficacy of nicotine replacement therapy for smoking cessation: a review of the literature. Drugs. 2013; 73: 407-426.

Fiore MC, Schroeder SA, Baker TB. Smoke, the chief killer--strategies for targeting combustible tobacco use. N Engl J Med. 2014; 370: 297-299.

Hughes JR, Carpenter MJ. Does smoking reduction increase future cessation and decrease disease risk? A qualitative review. Nicotine Tob Res. 2006; 8(6): 739-749.

Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

Moore D, Aveyard P, Wang D, Fry-Smith A, Barton P.  Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: systematic review and meta-analysis. BMJ. 2009; 338: b1024.

Stead LF, Lancaster T. Interventions to reduce harm from continued tobacco use. Cochrane Database of Systematic Reviews 2007, Issue 3.

Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. The Cochrane database of systematic reviews. 2012;11:CD000146. logo
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