Reduced smoking--an acceptable goal for the hopeless heavy smoker?

Smoking represents today by far the largest preventable cause of death. Data suggest annual premature deaths of 420,000 smokers [1] and of 53,000 passive smokers [2, 3] in the USA alone. A necessary step in the reduction of the smoking epidemic is the use of educational prevention programmes for those at risk of starting smoking, and initiatives to promote smoking cessation for smokers. Although there is no doubt about the clear long-term benefit of smoking cessation, both for the smoker as well as for the healthcare provider particularly as regards cancer and chronic obstructive pulmonary disease (COPD), comparatively little is known about the substantial short-term health and economic benefits of smoking cessation. The excess risk of myocardial infarction or stroke decreases by approximately 50% within the first year after stopping smoking [4]. Strategies for smoking cessation programmes are well known today and widely used. Nicotine replacement therapy remains the core of each strategy, particularly for nicotine dependent heavy smokers (smoking >20 cigarettes· day-1). Sustained quit rates (6 months and 1 yr success rates) are more frequent among light to moderate smokers compared to heavy smokers [5, 6]. Thus, relapse rates in heavy smokers are less favourable. The reasons are in most cases obvious: 1) Withdrawal symptoms in heavy smokers are more prominent mostly due to nicotine dependency. 2) Smoking cessation among heavy smokers usually requires a higher amount of willingness to change current behaviour and life style. 3) Coexistence of addictive dependencies such as alcoholism or even abuse of narcotic drugs is more often seen in heavy smokers. Recent data suggest that smoking diminishes the subjective perception of alcohol intoxication [7]. Development of Dupuytren's contracture is strongly related to alcoholism and to heavy smoking [8]. Smokers with alcohol problems undergoing cessation therapy with nicotine patches showed a significantly lower 1 yr quit rate (close to placebo) when compared to nonalcoholic smokers [9]. Thus, focusing only on smoking cessation without also addressing alcohol or drug dependence has a higher risk of failure. 4) Concerns of smokers regarding weight gain after smoking cessation is one of the most intriguing obstacles, particularly in female patients [10–12]. Recent data confirm the significant correlation between smoking and lower body mass index (BMI). Inversely, a higher relative body weight is found with smoking cessation [13]. 5) Heavy smokers most often need a tailored nicotine replacement strategy. Current available nicotine delivery systems (gum, patch, nasal spray, inhalation, …