Intended for healthcare professionals

Clinical Review ABC of smoking cessation

Harm reduction

BMJ 2004; 328 doi: (Published 08 April 2004) Cite this as: BMJ 2004;328:885
  1. Ann McNeill, independent consultant in public health and an honorary senior lecturer in the psychology department
  1. St George's Hospital Medical School, London


    Although the ideal for all smokers is to quit completely, a substantial proportion of smokers either do not want to stop smoking or have been unable to do so despite many attempts. Harm reduction strategies are aimed at reducing the adverse health effects of tobacco use in these individuals.

    Cutting down

    Cutting down on the number of cigarettes smoked each day is a common strategy used by smokers to reduce harm, to move towards quitting, or to save money. Some health professionals also advocatecutting down if smokers cannot or will not stop. No evidence exists, however, that major health risks are reduced by this strategy. The likely explanation for this is that smoking is primarily a nicotine seeking behaviour, and smokers who cut down tend to compensate by taking more and deeper puffs from each cigarette, and smoking more of it. This results in a much smaller proportional reduction in intake of nicotine (and in associated tar and other toxins) than the reduction in number of cigarettes smoked suggests.

    Prospective hazard ratios for death for smokers who cut down or quit compared with continuing heavy smokers. Adapted from Godtfredsen et al (Am J Epidemiol 2002;156: 994-1001

    Cutting down on cigarettes in conjunction with the use of nicotine replacement therapy (NRT) tomaintain nicotine levels is a more promising strategy, although NRT is not currently licensed in the United Kingdom or in many other countries for use in this way. Preliminary studies have suggested that this approach may help with sustained cigarette reduction and reduce intake of toxins, butno strong evidence exists yet of health benefit from this strategy.

    Switching to “low tar” cigarettes

    Many smokers who are concerned about the health effects of smoking switch to “low tar” cigarettes, in the belief that these are less dangerous than ordinary cigarettes. This perception has been encouraged by the tobacco …

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