As many smokers consider going cold turkey and abruptly quitting their smoking habit this holiday season, new evidence is emerging that committing to a long-term course of smoking cessation treatment that includes reducing smoking may be a more effective strategy than short-term treatment options.
In a study published today in the Archives of Internal Medicine, Anne M. Joseph, MD, MPH, of the University of Minnesota, and her colleagues randomly assigned smokers to receive 1 year of telephone-based care, including counseling and medication, or the usual smoking cessation treatment, which involves just 8 weeks of telephone-based care and medication. While most smoking cessation programs focus on total abstinence, the long-term care group in the study included strategies for different contingencies: when smokers were abstinent, when they had relapsed but were smoking less, or when they had resumed smoking at the same levels they had engaged in before they attempted to quit. At 18 months after the trial started, 30.2% of the smokers who received long-term care reported that they had not smoked in 6 months, compared with 23.5% in the usual-care group. Dr Joseph discussed the results with news@JAMA.
news@JAMA: Why do you believe the strategy involving longer-term care was more successful than usual care?
Dr Joseph: There are a number of hypotheses. They got more intensive treatment—almost double number of calls from a counselor, more minutes with the counselor on the phone, and more pharmacotherapy. We also tried to use same counselor for each patient over the course of treatment, and some of the patients developed a sense of accountability to that person. A lot of the patients talked about that as one of the things that was useful to them.
news@JAMA: Why did you include the smoking-reduction element?
Dr Joseph: We want to keep our eye on the prize of being abstinent but incorporate clinically relevant behavior we see in smokers. It’s common when people are trying to quit and are unsuccessful that there is a period where they smoke less before they go back to their previous levels of smoking. In a traditional cessation treatment paradigm, we’d call that a failure and the person would go back to smoking. In this model, we continue to work with them in an ongoing fashion. We ask them to set another quit date, which they are sometimes immediately able to do. Other times we ask if they could continue smoking at a reduced rate with the goal of quitting in the future.
news@JAMA: How might smoking reduction help smokers quit?
Dr Joseph: It might build confidence or it might reduce their dependence on nicotine. It also helped the counselors. When they encountered a patient who had reduced their smoking from 15 cigarettes a day to 5, the counselor could say, “That’s so much better than before. Let’s see if we can go further and get you to quit.” It’s similar to what a clinician would do with someone with high blood pressure who has lowered their blood pressure but still needs to lower it more. We’ve used this chronic disease model in lots of diseases, but it has been all or nothing with smoking cessation.
news@JAMA: How long is long enough?
Dr Joseph: Our intervention went on for a year. We were partly confined by feasibility. But in the long-term care group, through 12 months we were still adding sustained quitters. I would say it should be longer than a year or until the person stops.
news@JAMA: What do you think are the key take-home messages for clinicians and for individuals who would like to quit smoking?
Dr Joseph: For clinicians, once a patient expresses a desire to be a nonsmoker or to quit, it should be addressed at every visit. These data would suggest that we as clinicians would do better if we tried to tweak the cessation treatment at each visit. I would also tell patients that it often takes multiple attempts to be successful—on average, it takes 5 quit attempts—and you don’t have to go back to the pattern of smoking you had before the attempt. You can continue to try to modify your behavior.