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Randomised controlled trial
After precessation nicotine replacement therapy, abrupt cessation increases abstinence more than gradual cessation in smokers ready to quit
  1. Elias M Klemperer,
  2. John R Hughes
  1. University of Vermont, Burlington, Vermont, USA
  1. Correspondence to: Elias M Klemperer, University of Vermont, UHC Campus, Mailstop 482 OH4, 1 S. Prospect St., Burlington, VT 05401, USA; elias.klemperer{at}

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Most guidelines recommend abrupt smoking cessation; however, gradual cessation is common. Reducing cigarettes per day (CPD) with nicotine replacement therapy (NRT) increases cessation among smokers who are not ready to quit.1 However, whether gradual reduction is effective for smokers who want to quit now is unclear.2


This randomised controlled trial compared gradual cessation (ie, reduction in CPD) with abrupt cessation among smokers ready to quit (N=697). The gradual-cessation group received 2 weeks of NRT patches, short-acting NRT and behavioural support to reduce smoking by 75% prior to their quit date. The abrupt-cessation group received 2 weeks of NRT-patches and behavioural support with instructions to smoke as usual prior to their quit date. All participants received NRT and behavioural support after their quit date. Primary outcomes were validated abstinence at 4 weeks and 6 months after the quit date.


Most participants used the NRT patch (81–90%). Overall, 39% of the gradual-cessation and 49% of the abrupt-cessation groups were abstinent for 4 weeks after their quit date (RR=0.80 (95% CI 0.66 to 0.93)). Prolonged and point-prevalence abstinence at 6 months were also less likely in the gradual-cessation than the abrupt-cessation group (prolonged: 16% of the gradual-cessation and 22% of the abrupt-cessation groups, RR=0.71 (95% CI 0.46 to 0.91); point prevalence: 18% of the gradual-cessation and 17% of the abrupt-cessation groups, RR=0.70 (95% CI 0.51 to 0.97)).


We commend the authors for a rigorous test of this important issue. The trial recruited smokers from 31 general practitioners across England, which increased external validity. The conditions differed only in the treatment delivered during the 2 weeks of precessation NRT, which increased internal validity. Participants in the gradual-cessation group achieved substantial reduction in CPD (68%) during the 2-week precessation period. We have three comments regarding the interpretation of the authors’ findings.

First, the study included smokers already motivated to quit smoking. Reducing CPD has also been used among smokers who are not ready to quit to motivate them. This use increases the likelihood of eventual cessation compared to no treatment.1 Thus, it is important to distinguish the current study of those already motivated versus prior studies of using reduction in those not motivated to quit.

Second, both groups received precessation NRT; thus, what the authors label ‘abrupt cessation’ may be different than what is commonly thought of as abrupt (ie, quitting prior to initiating NRT). Precessation NRT appears to be an effective strategy to increase cessation.3 ,4 Providing both groups with precessation NRT increased the internal validity of the study. However, abstinence in the ‘abrupt’ cessation group may have been inflated due to the use of precessation NRT.

Third, the findings may not apply to the majority of smokers who do not use NRT before quitting (current labelling does not recommend precessation NRT in many countries).

Implications for practice

This trial provides evidence that, among smokers who are ready to quit, instructions to quit abruptly after precessation NRT is more effective than instructions to quit after reducing CPD with precessation NRT.


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  • Funding NIDA T32 DA07242.

  • Competing interests EMK has nothing to disclose. JRH has received consulting and speaking fees from several companies that develop or market pharmacological and behavioural treatments for smoking cessation or harm reduction and from several non-profit organisations that promote tobacco control. He also consults (without payment) for Swedish match.

  • Provenance and peer review Commissioned; internally peer reviewed.