abrupt vs gradual smoking cessation; patch 2 weeks before quitting

an English study tested two strategies to achieve smoking cessation: a gradual vs abrupt approach (see smoking cessation abrupt vs gradual AIM2016 in dropbox, or doi:10.7326/M14-2805). the background is that most guidelines recommend abrupt cessation ("setting a quit date and then stopping cold turkey"), though many smokers report stopping more gradually. details of the study:

--697 adult smokers (at least 15 cigarettes/d), recruited to quit smoking, choosing a quit date 2 weeks after starting the program. these patients were randomized to either an abrupt cessation program, smoking normally then stopping at the quit date, or a more gradual reduction program, reducing their smoking by daily increments to achieve a 50% reduction by the end of the first week, and a 75% reduction by the end of the second week and then stopping. 

--both groups received behavioral support from nurses and used nicotine replacement therapy (NRT) before and after the quit date (it is not quite explicit, but i think they all used 21-mg patches in the 2 weeks before the quit date, and those in the gradual group also used short acting NRT such as gum or lozenges. they all used both patches and short-acting NRT after the quit date).

--median age 49, 50% male, 94% white, 50% with postsecondary school education, 55% working, 39% lived with a smoker, median prior quit attempts = 2, 20 cigarettes/d, expired CO=24 ppm, median Fagerstrom Test for Cigarette Dependence score = 6 (ie, highly dependent), 51% preferred gradual cessation and 32% abrupt.

--behavioral therapy focused on the commitment to abstain, with early support when withdrawal symptoms are worst/relapse more likely.

--nurses saw the patient initially, 1 day before the quit date, weekly for 4 weeks, and finally 8 weeks after the quit date

--results, comparing the gradual vs abrupt quit rates:

    --at 4 weeks, 39.2% (34.0-44.4%) vs 49.0% (43.8-54.2%); RR 0.80 (0.66-0.93)

    --at 6 months, 15.5% (12.0-19.7%) vs 22.0% (18.0-26.6%); RR 0.71 (0.446-0.91)

    --fewer people made a quit attempt (>24 hours of self-reported abstinence) in the gradual cessation group (61.4% vs 71% in the abrupt group; though in the gradual group, they had reduced their cigarette consumption by 48% by the end of the first pre-cessation week (target 50%) and by 68% by the end of the second week (target 75%) 

    ​--and, participants who preferred gradual vs abrupt cessation prior to randomization were less likely to be abstinent at 4 weeks (38.3% vs 52.2%) 

    --no significant study-related adverse events

so, a few points:

-- this study was done in 31 primary care practices in London. their explanation for the lack of racial diversity was that the minorities in London tend to smoke much less than the majority white population. but this difference may limit the generalizability of the results to other populations.

--those who preferred the gradual cessation method did worse, independent of which group they were assigned to [this is consistent with my practice: very few people who try to cut back gradually do actually achieve abstinence, though very few of them do such a severe reduction program as above, with 75% reduction in 2 weeks]

--this study raises the issue of starting patches prior to the quit date.  in looking at their reference for this (Addiction 2008; 103: 557), this meta-analysis of 4 studies actually showed that patches given 2-4 weeks prior to smoking cessation led to a 2-fold increased long-term quit rate, at both 6 weeks and 6 months. this is not something i have prescribed, though now will do so, 2 weeks prior to the quit date.

--the people in this study were really nicotine-dependent, and to me their 49% cessation rate at 4 weeks in the abrupt group is very impressive, as is their 22% at 6 months. especially since smoking an average of a pack a day is not only very addicting physiologically, but involves a pretty extensive amount of time smoking each day, with many more smoking-related associations than those who smoke just a few cigarettes/d (ie, those who smoke throughout the day may well associate smoking with many different things: waking up, after meals, hanging out with friends, having a beer....), much more so than those who smoke a cigarette on awakening and then after dinner. So, psychologically, heavy smokers also have more cigarette-related associations to deal with in order to quit.

--i know some clinicians are trying to get patients to cut back to 1/2 ppd (10 cigarettes) prior to setting a quit date, thinking that the overall chances of success would be higher. i am not aware of data looking at this, but this study suggests otherwise.

--so, i think this data and that of other studies (some but not all) suggest that we push for a more abrupt quit date, ideally with pre-cessation patches (if that is the method chosen). however, as with all of these substance dependencies, there will be many people who are unable to adhere to such a program, and our goal continues to be harm reduction and allowing the patient to determine their own approach to nicotine reduction. and it is important to remember that most smokers take 3-4 quit attempts to finally succeed.