18.3 Smoking reduction

Last updated: August 2016 

Suggested citation: Greenhalgh, EM, & Scollo, MM 18.3 Smoking reduction. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/18-3-reduction

A strategy often adopted by smokers who are trying to reduce their risk of adverse health outcomes is cutting down on the number of cigarettes smoked each day.1 The validity of this approach as a strategy for reducing harm is drawn from large amounts of research showing a dose–response relationship between level of consumption and health risks; that is, the association between smoking and many diseases becomes stronger with more cigarettes smoked each day. However, despite this relationship, the evidence does not support cutting down as an effective method to alleviate risk.2

One explanation for this lack of risk reduction is compensation: smokers who cut down tend to take more and deeper puffs from each cigarette, and smoke more of it. In turn, there is a much smaller proportional reduction in intake of nicotine, tar, and other toxins than the amount of cutting down might predict.3 Further, the relationship between exposure to tobacco smoke and harm is not linear.1,4 For example, a low level of tobacco exposure (4–7 cigarettes per day) has about 70% of the effect of heavy smoking (at least 23 cigarettes per day) on risk for cardiovascular disease.5 A longitudinal study of health outcomes in light smokers found that smoking 1–4 cigarettes per day was associated with a significantly higher risk of dying from ischaemic heart disease and from all causes, and from lung cancer in women. Light smoking women were five times more likely and men three times more likely to develop lung cancer compared with non-smokers.6

A 2007 systematic review that that examined the health effects of reducing smoking found a small health benefit following a substantial reduction in smoking, but concluded that further studies are needed to determine any long-term effects.7 A Korean study found no association between smoking reduction and all cancer risk except for a significant reduction in risk of lung cancer, but the reduction in risk was disproportionate to the reduction in consumption, and smaller than expected.8 Other studies have found no evidence that smoking reduction is an effective means of reducing mortality risk.9,10  

The primary benefit of cutting down seems to be its role as a step toward quitting,9, 11 although this may be a less effective strategy than going ‘cold turkey’.12  A 2015 review exploring the usefulness of cutting down determined that smokers who reduce the number of daily cigarettes smoked are more likely to attempt and actually achieve smoking cessation, particularly when combined with NRT.13 It should also be noted that the existing epidemiological evidence on cutting down providing no health benefit is generally in the context of no additional source of nicotine, such as NRT or e-cigarettes. Obtaining nicotine from an alternative source may reduce some of the compensatory smoking behaviour that would otherwise limit the benefit from cutting down. Studies of smokers cutting down while using NRT have found that while blood nicotine levels generally remain stable or slightly higher, carbon monoxide readings decreased.14-16 This has led some to advocate concomitant use of NRT while smoking as a harm reduction strategy.17, 18 Evidence suggests that use of NRT to ‘cut down to quit’ is effective and cost effective compared to no quit attempt,11 but data on the health risks/benefits of long-term dual use of NRT and cigarettes are lacking.  

Relevant news and research

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1. Britton J and Bogdanovica I. Electronic cigarettes: a report commissioned by Public Health England.  2014. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/311887/Ecigarettes_report.pdf .

2. Chapman S. E-cigarettes: the best and the worst case scenarios for public health. British Medical Journal, 2014; 349:g5512. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25204397

3. McNeill A. Harm reduction. Review. British Medical Journal, 2004; 328(7444):885–7. Available from: http://www.bmj.com/cgi/content/full/328/7444/885

4. Schane RE, Ling PM, and Glantz SA. Health effects of light and intermittent smoking: a review. Circulation, 2010; 121(13):1518–22. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2865193/

5. Pope CA, Burnett RT, Krewski D, Jerrett M, Shi Y, et al. Cardiovascular mortality and exposure to airborne fine particulate matter and cigarette smoke shape of the exposure-response relationship. Circulation, 2009; 120(11):941–48. Available from: http://circ.ahajournals.org/content/120/11/941.short

6. Bjartveit K and Tverdal A. Health consequences of smoking 1–4 cigarettes per day. Tobacco Control, 2005; 14(5):315–20. Available from: http://tobaccocontrol.bmj.com/content/14/5/315.full.html

7. Pisinger C and Godtfredsen NS. Is there a health benefit of reduced tobacco consumption? A systematic review. Nicotine & Tobacco Research, 2007; 9(6):631–46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17558820

8. Song Y-M, Sung J, and Cho H-J. Reduction and cessation of cigarette smoking and risk of cancer: a cohort study of Korean men. Journal of Clinical Oncology, 2008; 26(31):5101–6. Available from: http://jco.ascopubs.org/content/26/31/5101.short

9. Hart C, Gruer L, and Bauld L. Does smoking reduction in midlife reduce mortality risk? Results of 2 long-term prospective cohort studies of men and women in Scotland. American Journal of Epidemiology, 2013; 178(5):770–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23825165

10. Tverdal A and Bjartveit K. Health consequences of reduced daily cigarette consumption. Tobacco Control, 2006; 15(6):472–80. Available from: http://tobaccocontrol.bmj.com/content/15/6/472.full

11. Wang D, Connock M, Barton P, Fry-Smith A, Aveyard P, et al. 'Cut down to quit' with nicotine replacement therapies in smoking cessation: a systematic review of effectiveness and economic analysis. Health Technology Assessment, 2008; 12(2):1–135. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18093448

12. Lindson-Hawley N, Banting M, West R, Michie S, Shinkins B, et al. Gradual versus abrupt smoking cessation: A randomized, controlled noninferiority trial. Annals of Internal Medicine, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26975007

13. Begh R, Lindson-Hawley N, and Aveyard P. Does reduced smoking if you can't stop make any difference? BMC Medicine, 2015; 13:257. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26456865

14. Dalack GW and Meador-Woodruff JH. Acute feasibility and safety of a smoking reduction strategy for smokers with schizophrenia. Nicotine & Tobacco Research, 1999; 1(1):53–7. Available from: http://ntr.oxfordjournals.org/content/1/1/53.abstract

15. Bolliger CT, Zellweger J-P, Danielsson T, van Biljon X, Robidou A, et al. Smoking reduction with oral nicotine inhalers: Double blind, randomised clinical trial of efficacy and safety. British Medical Journal, 2000; 321(7257):329–33. Available from: www.ncbi.nlm.nih.gov/pubmed/0010926587

16. Fagerström KO, Tejding R, Westin A, and Lunell E. Aiding reduction of smoking with nicotine replacement medications: Hope for the recalcitrant smoker? Tobacco Control, 1997; 6(4):311–6. Available from: http://tobaccocontrol.bmj.com/content/6/4/311.abstract

17. Bittoun R, Barone M, Mendelsohn CP, Elcombe EL, and Glozier N. Promoting positive attitudes of tobacco-dependent mental health patients towards NRT-supported harm reduction and smoking cessation. Australian and New Zealand Journal of Psychiatry, 2014:0004867414535673. Available from: http://anp.sagepub.com/content/early/2014/06/05/0004867414535673

18. Cohen B, Harm reduction in substance use: smoking cessation for marginalised populations. Bayside Medicare Local; 2014. Available from: http://bml.org.au/BML%20Smoking%20Cessation%20in%20Marginalised%20Populations.pdf