There are three main conclusions that can be drawn from this study. First, reducing smoking among adolescents is achievable, although whether this reduction has beneficial effects is uncertain and debatable. The results of this study showed that nearly half of the participants (49.4%, n=41) reduced their smoking by at least 50%. However, participants’ level of reduction waned by the six-month follow-up visit to a reduction of only 27.1% of their baseline smoking rate.
Second, there were no important differences in treatment groups with regard to reducing smoking or the related outcomes. Interestingly, nicotine replacement seems to reduce compensatory smoking as measured by CO/cigarette and cotinine/cigarette, but only at the 3-month follow-up.
Third, reducing smoking led to only a modest reduction in some biomarkers (CO), but not others (total NNAL). Unless smoking reduction is sustained and perhaps reduced further, decreasing smoking may not lead to substantial reductions in toxicant uptake (see Hecht et al., 2004
As a cautionary note, although participants reduced their smoking level at the six-month follow-up visit, their CO and cotinine levels increased. In some participants (n=11), although the mean of the baseline cotinine levels was lower than the level observed at follow-up, one of the baseline cotinine values was in fact higher. We cannot totally rule out the effect of cigarette reduction on increased smoke exposure after treatment in our smokers. A subset of smokers may have learned to smoke their cigarettes more efficiently (e.g., puffing harder on a cigarette). The increase in CO and cotinine levels could be due to inaccurate reporting of smoking rate by the participants (e.g., social desirability influences) or measurements made at times when there were no restrictions on smoking (summer months or holidays). After looking at the data, independent investigators believed observed results were most likely a function of greater free time, variability in smoking patterns and the trajectory towards increased smoking behavior.
There are several limitations of this study. First, there was no placebo for the nicotine patch or the nicotine gum, nor was the study double-blinded. This study also had limited power to detect inter-group differences due to being an observational and safety study. Second, feasibility of the replicating this study in the community may be limited in terms of the cost of providing medication, CBT and participant compensation. Third, this sample may be unrepresentative of adolescent smokers. There was a very high level of co-morbidity among participants. This may be because 3 of the 14 schools where the study was conducted were for students who have recently completed alcohol or drug treatment. A final consideration is whether advertising a smoking reduction program at schools could influence adolescents to think that smoking at a reduced level poses no health issues or that quitting isn’t necessary.
In summary, reduction in smoking may be a potential method to aid adolescents who are unable or unwilling to quit, but should not be an end goal. Furthermore, some caution should be exercised because adolescents may learn to smoke more efficiently when reducing smoking and the health benefits from reduction are unknown. Future research is necessary to determine if reduction could facilitate an abstinence attempt in adolescent smokers not immediately interested in quitting.