Quitting smoking - RRT

The clinical question

Smoking damages the heart and blood vessels. It increases the risk of developing heart and circulatory diseases, as well as cancer. Quitting smoking is the best thing anyone can do to protect their health in general, and their heart health in particular.

But stopping smoking is challenging. Many people stop for a while, only to relapse when cigarette withdrawal symptoms set in. Most guidelines for quitting advise doing so abruptly. But many smokers try cutting down gradually first, before stopping ‘cold turkey’, thinking this could be less challenging. Professor Paul Aveyard and his team at the University of Birmingham designed the ‘Rapid Reduction Trial’ (RRT), which was funded by the BHF, to compare those two quitting strategies. 

What did the study involve?

Between 2009 and 2011, the RRT trial recruited 697 adult smokers across the UK who smoked at least 15 cigarettes per day. They were randomly assigned to either:

• Gradually reduce tobacco use over 2 weeks before a planned quit day (gradual-cessation group). Participants in this group received short-acting nicotine replacement therapy (NRT) before the quit day.
• Stop smoking completely on a planned quit day (abrupt-cessation group). Participants in this group were asked to smoke as normal up to their quit day.

After the quit day, both groups:

• Were prescribed nicotine patches and short-acting NRT to help with cravings. 
• Had behavioural counselling on a weekly basis, from 2 weeks before to 4 weeks after the quit day. This provided support early in the quitting process when withdrawal symptoms are worst and relapse is most likely.

The team monitored whether the participants managed to abstain from smoking at follow up sessions after 4 weeks and 6 months. To help with this, a breath test was used that detects how much carbon monoxide – a poisonous gas in cigarette smoke – is in the body. 

What did the study show?

• 78 of 355 people (22%) in the abrupt cessation group were still not smoking after 6 months.
• 53 of 342 people (~16%) were still not smoking in the gradual cessation group.
• This meant that participants who quit smoking abruptly were around 30% more likely to be abstinent after 6 months.

Why is the study important?

Quitting smoking is challenging. Many people who smoke are addicted, mainly due to the nicotine that cigarettes release when you smoke them. Smokers often attempt to quit several times before they actually succeed. This study revealed that, in this group of smokers, stopping smoking abruptly was more likely to lead to abstinence at 6 months than gradual quitting. But that doesn’t mean a gradual ‘cutting down’ can’t work for some people. Some people won’t ever want to quit abruptly. And we know that getting support from professionals, including counselling and medication, may be more important to increase the chances of beating a smoking habit for good than how a person chooses to quit.

Professor Aveyard said: “We used to believe that ‘cutting down’ wasn’t really a great idea and that the best way to stop smoking was to smoke as normal and then have a ‘quit day’ and then take it from there. And to be honest that probably is still the best way to go for most people."

As part of the NHS Stop Smoking service, people who smoke can be referred to a ‘stop smoking advisor’ who can offer information, advice and support on ways to quit. This can include finding ways to cut down before finally quitting.

Study details

"Rapid reduction versus abrupt quitting for smokers who want to stop soon: a randomised controlled non-inferiority trial."
Award reference:  PG/08/047/25082
Principal Investigator: Professor Paul Aveyard, University of Birmingham
Trial registration number: ISRCTN22526020

Publication details

Lindson-Hawley N, Banting M, West R, Michie S, Shinkins B, Aveyard P. Gradual Versus Abrupt Smoking Cessation: A Randomized, Controlled Noninferiority Trial. Ann Intern Med. 2016;164(9):585-92.