Quitting smoking overnight 'better than cutting down gradually'

Behind the Headlines

Tuesday March 15 2016

There is a wide range of advice and help that can help increase your chances of quitting

Nicotine replacement therapy can help relieve cigarette cravings

"Want to quit smoking? Forget trying to cut down, if you really want to kick the habit 'going cold turkey is the best option'," is the headline from the Mail Online.

The news website reports on a trial by UK-based researchers that aimed to assess whether it's better to stop smoking gradually or abruptly. 

The researchers included almost 700 people and randomly assigned them to a gradual or abrupt stop in cigarette use. After four weeks, 39.2% of participants that gradually stopped smoking were still abstinent, compared with 49.0% that stopped smoking abruptly.

Both groups had access to nicotine replacement therapy (NRT), such as patches or gum, after the quit day. At six months, the proportion of participants that still abstained from smoking had reduced to 15.5% in the gradual group and 22.0% in the abrupt group.

The findings of this trial show promise, but going "cold turkey", as the headline suggests, may not be for everyone.

That said, setting a designated "quit day" can be useful, as you can put into place "strategies" that can help you improve your chances of quitting.

These include getting adequate stocks of NRT, or even something as simple as finding something to do with your hands – some people find worry beads very useful. 

You can find your nearest NHS Stop Smoking Service on the NHS Smokefree website, or you can call the Smokefree National Helpline to speak to a trained adviser on 0300 123 1044. 

What type of NRT is best?

By far the most popular NRT is e-cigarettes. But critics of e-cigarettes say they contain no "exit strategy": you're simply replacing one long-term nicotine delivery system with another.

 

Other types of NRT, such as gum, patches and throat sprays, are designed to wean you off your nicotine addiction over several months. Depending on your initial level of addiction, this can take 8 to 12 weeks.

 

There are also two types of medication, Zyban (bupropion) and Champix (varenicline), that can help relieve cravings.

 

Read more about stop smoking treatments

Where did the story come from?

The study was carried out by researchers from the University of Oxford, the University of Birmingham, and University College London. Funding was provided by the British Heart Foundation.

It was published in the peer-reviewed journal, Annals of Internal Medicine.

The research has been presented accurately in the media. However, there has been no mention of the reduction in people remaining abstinent at six months, or whether this is a good method for long-term smoking cessation.

The press coverage does explain that for those who find it hard to stop abruptly, it is still better to attempt to cut down on smoking than do nothing at all.

Many of the reports include the phrase "going cold turkey". This is unhelpful, as it implies that people who stop abruptly have no treatment to help them cope with nicotine withdrawal symptoms.

The truth is that NRT can significantly reduce cigarette cravings. Evidence suggests people who quit using NRT are more likely to succeed than people who try to quit using willpower alone.  

What kind of research was this?

This was a randomised controlled trial that aimed to assess the success of stopping smoking by a gradual method, compared with an abrupt stop.

This study design is best for examining such methods, as in theory the groups should be balanced for potential confounders and the differences in outcomes are the result of the intervention.   

What did the research involve?

The researchers included adult smokers who were addicted to tobacco but willing to quit.

Addiction was defined as any of the following:

  • smoking at least 15 cigarettes a day
  • smoking at least 12.5g of loose-leaf tobacco (a standard small pack of rolling tobacco)
  • end expiratory carbon monoxide concentration of at least 15 parts per million (ppm) – this is a measure of how much carbon monoxide a person exhales when breathing

Potential participants were excluded if they were:

  • currently receiving smoking cessation treatment
  • not able to take NRT
  • participating in other medical trials
  • not able to meet the demands of the trial

Participants were randomly assigned to stop smoking abruptly or reduce smoking gradually by 75% in the two weeks before quitting.

Participants from both groups were asked to set a "quit day" two weeks after joining the trial. The gradual group were to reduce their smoking by 50% in the first week and to 25% by the end of the second week. Participants in the abrupt group were asked to smoke as normal and not reduce between joining the trial and quit day.

The gradual-cessation group received short-acting NRT devices (such as gum or spray) as well as longer-acting nicotine patches before the quit day. The abrupt-cessation group only received nicotine patches before the quit day. Both groups had access to behavioural counselling, nicotine patches, and short-acting NRT after the quit day.

Participant characteristics were collected at the start of the study. These included:

  • smoking history
  • nicotine dependence
  • preference for gradual or abrupt cessation

At follow-up sessions in the clinic, assessments were made of the amount smoked and measured cotinine in the saliva – used as a marker for exposure to tobacco smoke – and exhaled carbon monoxide concentrations. Tobacco withdrawal symptoms were also measured using a standardised mood and physical symptoms scale.

The researchers measured abstinence from smoking four weeks and six months after the quit day. The analysis used assumes that any participants lost to follow-up were smokers.  

What were the basic results?

From June 2009 to December 2011, there were a total of 697 participants included in the study – 355 assigned to the abrupt group and 342 to gradual.

After four weeks, 39.2% of participants that gradually stopped smoking were still abstinent (95% confidence interval [CI] 34.0% to 44.4%) compared with 49.0% of those that stopped smoking abruptly (95% CI 43.8% to 54.2%).

This means an increase of about 20% in quit rates for those stopping abruptly (relative risk [RR] 0.80, 95% CI 0.66 to 0.93).

The longer-term findings saw that at six months, the proportion of participants that still abstained from smoking had reduced to 15.5% in the gradual-cessation group and 22.0% in the abrupt-cessation group. 

How did the researchers interpret the results?

The researchers concluded that, "Quitting smoking abruptly is more likely to lead to lasting abstinence than cutting down first, even for smokers who initially prefer to quit by gradual reduction." 

Conclusion

This was a well-designed randomised controlled trial which aimed to assess whether the best method to stop smoking is by gradual reduction or an abrupt stop.

Researchers found more people in the abrupt-cessation group continued to abstain from smoking at four weeks and six months, compared with those who gradually reduced smoking.

The trial's strengths include the design, methods and analysis used. The researchers have made attempts to minimise the risk of bias, where possible.

The population sample is large, which allows for greater certainty that the findings are not purely down to chance. The follow-up period of six months allowed researchers to assess the longer-term effect of cessation methods.

As the authors state, limitations are that the sample is not representative of the UK's ethnic mix, as non-white groups formed only 6% of the trial population.

This trial addresses a major public health issue. There has been a large amount of research designed to find the best and most effective methods of smoking cessation, particularly longer-term methods.

The idea that suddenly stopping smoking may be more effective than gradually cutting down, in terms of quitting, seems plausible.

If we can consider nicotine addiction like a plaster on the skin, pulling it right off in one sudden move, rather than slowly and painfully peeling it off, could be more effective.

But when it comes to stopping smoking, one size does not fit all. It may be necessary to seek help and support from a Stop Smoking Service or GP, who can tailor a quitting method to your needs.

Find out the six simple steps you can take to quit smoking.

Analysis by Bazian. Edited by NHS Choices. Follow NHS Choices on Twitter. Join the Healthy Evidence forum.

Analysis by Bazian

Edited by NHS Choices

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Media last reviewed: 18/06/2015

Next review due: 18/06/2017

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