Impact of Self-Initiated Pre-quit Smoking Reduction on Cessation Rates: Results of a Clinical Trial of Smoking Cessation among Female Prisoners

1. Introduction

Smoking remains the leading cause of preventable death in the United States and novel interventions are needed to assist smokers in quitting (MMWR, 2007). While smoking prevalence in the general population has declined in recent years, smoking remains highly prevalent in prison populations with approximately 70-80% of prisoners identified as current smokers (Cropsey, Eldridge, Weaver, Villalobos, & Stitzer, 2006; Sieminska, Jassem, & Konopa, 2006; Belcher, Butler, Richmond, Wodak, & Wilhelm, 2006; Cropsey & Kristeller, 2003; 2005; Conklin, Lincoln, Tuthill, 2000; Colsher et al., 1992; Cropsey, Eldridge, and Ladner, 2004). These high rates of smoking are not gender specific (Cropsey & Kristeller, 2003; 2005; Cropsey et al., 2006; Cropsey et al., 2008) and have a grave impact on the health of prisoners. The most common medical problems in prisoners are smoking-related illnesses such as heart disease, respiratory problems, and liver and kidney disease (Maruschak & Beck, 2001). Despite the fact that smoking cessation treatment is clearly needed for incarcerated populations and the incarceration period presents an ideal opportunity to intervene, few studies of cessation interventions have been conducted in correctional facilities.

There are many contributing factors for the lack of cessation treatment in prisons. One key barrier is the cost to develop and implement evidence-based tobacco cessation treatment. Despite evidence suggesting that treating tobacco use would actually save costs incurred from the treatment of smoking-related health conditions, there has not been enough fiscal support to offer treatment in many institutions. Smoking bans in correctional facilities have been a more recent phenomenon and over half of states have implemented smoking bans within their facilities (Kauffman, Ferketich, & Wewers, 2008). While smoking bans can be an important public health policy to reduce smoking, implementing these bans in prisons without cessation treatment creates problems with an underground economy and may not lead to sustained cessation (Cropsey et al., 2003; Kauffman, Ferketich, & Wewers, 2008). A review of smoking policies in prisons found that while most institutions with indoor tobacco bans (86%) reported having some form of tobacco treatment, few (<40%) continued such programs after the initial period of introducing the ban (Kauffman, Ferketich, & Wewers, 2008). With new inmates entering prison daily, treatment to address abrupt cessation due to smoking bans will continue to be needed.

One strategy that has recently been investigated is smoking reduction as a precursor to cessation; i.e., gradual cessation. Reduction interventions generally consist of either structured reductions (e.g., having participants reduce their cpd by a certain percentage each week until they are close to smoking no cigarettes and can quit) or an unstructured reduction (allowing the participant to decide the rate to reduce their smoking). Reduction techniques may include behavioral treatment, pharmacotherapy, or both. Reduction in advance of a planned quit attempt may enhance likelihood of eventual success (Rose & Behm, 2004), particularly if the individual gains self-efficacy and/or lessens nicotine dependence through reduction (Carpenter, Hughes, & Keely, 2003; Carpenter, Hughes, Solomon, & Callas, 2004).

Smoking reduction has generally been examined as a potential marker or precursor of future quitting behavior among otherwise unmotivated smokers or as a directed intervention prior to a quit attempt. Such was the nature of the studies reviewed by Hughes and Carpenter (2006) where outcomes were examined in smokers that were not motivated to quit prior to the reduction initiation. They concluded that smoking reduction promotes eventual cessation and does not hinder overall motivation to quit (Hughes & Carpenter, 2006). However, a more recent review by Lindson, Aveyard, and Hughes (2010) found no appreciable differences between standard, abrupt quit attempts and reduction methods.

Two studies by Cinciripini and colleagues have looked at gradual reduction in smokers who were motivated to quit. The first looked at scheduled reduction versus minimal contact and found that reduction significantly improved cessation outcomes through one year follow-up (Cinciripini et al., 1994). The second study tested scheduled gradual reduction versus nonscheduled reduction (reducing cpd by eliminating whichever cigarettes participants chose), scheduled non-reduction (continue smoking the same amount at fixed intervals) or nonscheduled non-reduction (smoke the same amount as usual). They found that the scheduled reduction group had the best abstinence rates and the non-scheduled reduction had the worst, suggesting that the structure provided by scheduling may play a key role in success (Cinciripini, et al., 1995). However, neither study looked at self-initiated reduction.

There are reasons to believe gradual cessation techniques may be useful for promoting cessation in recalcitrant prison populations. One reason is that reduction can serve as the first step in the cessation process by increasing the participant's self-efficacy (Bandura & Adams, 1977; Hughes & Carpenter, 2006). This could be particularly useful in a prison population with markedly less access to positive reinforcement and limited treatment options. A second reason gradual cessation may be a useful approach for prisoners is that it slowly reduces nicotine dependence, which is a well-established barrier to cessation success (Colby et. al. 2000; Shadel et al., 2000; Hughes & Carpenter, 2006).

The optimal test of a reduction intervention on eventual cessation would be to randomize prisoners to either a reduction versus no reduction intervention prior to cessation. While no such test has been conducted among prisoners, the present study, based on a secondary analysis of a recently completed cessation trial (Cropsey et al., 2008), offers an indirect test of this. We compared female prisoners who self-selected to reduce during a 6-month interval prior to their enrollment in a smoking cessation program to those who did not. We hypothesized that self-initiated reduction would be positively correlated with subsequent quit success.

2. Method

3. Results

4. Discussion

Our study showed that the smokers who reduced prior to their quit attempt showed better cessation rates during initial post-quit weeks of the smoking cessation program than did those who did not reduce. However, these effects disappeared by the end of treatment and at follow-up points. The finding of a short-term improvement of cessation outcomes for those participants who evidenced pre-quit smoking reduction is inconsistent with null findings from previous studies (Hughes et al., 1999). The fact that these differences in cessation outcomes did not sustain through follow-up was consistent with most previous findings (Pisinger et al., 2005), with the one notable exception being the study by Falba and colleagues (2004) which showed long-term (two year) benefits associated with moderate-large reductions versus no reduction at all. In our study we found no long-term quit benefit for self-initiated reduction versus no reduction. It is important to note, however, the extent of reduction in our sample may have been smaller than that observed in previous studies given that fact that we compared any reduction versus none at all. Finally, the findings of this study are similar to those of Hughes and Carpenter (2006) in refuting the idea that pre-quit reduction hinders cessation. While we found no sustainable improvement in cessation for those that were able to reduce smoking, we also found no evidence of a negative impact of reduction.

This study proposes an interesting theory regarding which smokers attempt to reduce smoking prior to their established quit date. We found that the heaviest smokers were more inclined to reduce, while lighter smokers did not reduce their cpd prior to the quit date. A possible explanation for this is that lighter smokers may feel less dependent upon nicotine and anticipate less difficulty in quitting, while heavy, chronic smokers may have attempted to quit in the past and anticipate more difficulty during cessation. Partial support for this is found with the fact that individuals who reduced had slightly higher scores on the FTND, although these differences were not statistically significant. Alternatively, since non-reducers were similar to reducers in the highest number of cigarettes ever smoked in their lifetime, they may represent a group that had cut down gradually prior to entering the study, but had been unable to completely quit on their own and were relying on the intervention to help them quit or reduce further. No significant differences were found between the reduction groups on baseline Stage of Change which suggests that both groups were at a similar point of motivation to quit.

Our study had several limitations. The first is the lack of a scheduled reduction condition to allow us to test whether structured intervals would improve outcomes as seen in a previous study (Cinciripini et al., 1995). Group assignments were based on participant-reported reductions in cpd. While CO expirations served as a biochemical indication of smoking abstinence, we did not use it as the main indicator of reduction given the impact of time lapse on CO concentration, which could inadvertently miss smoker's who may have reduced their cpd, but smoked their last cigarette immediately prior to the collection of the sample. Further, given that this study involved a female prisoner population, it is not clear how these results would apply to non-prisoner populations, although they likely generalize to other correctional settings since male and female prisoners have similar smoking rates (Cropsey et al., 2004). Given that these smokers were not instructed to reduce on their own or given any strategies for doing so, this study is not comparable to other studies which have specifically instructed or assisted participants to reduce smoking. Also, we do not know if cessation outcomes would extend beyond prisoner release, i.e., long term. There is a reasonable expectation that some successful quitters will relapse once they return to the community. While the scope of this study was to compare cessation outcomes between smokers who made any self-directed change in their smoking behavior versus those that did not, it may be useful in future studies to examine outcomes based on the amount of reduction.

Despite these limitations, this study contributes to existing cessation literature in that it is the first to examine the impact of participant-initiated reduction on smoking cessation in a prison population. As previously noted, studies on scheduled reduction have shown more promising results; our data suggest that reduction might be promising as a pre-quit strategy with this population, although a subsequent study with this population should directly test this hypothesis. Self- initiated smoking reduction may serve as a marker for participant motivation to quit smoking although this was not apparent on baseline Stage of Change measure. Nevertheless, the limited and short-lived nature of the improved outcomes noted suggest that more intensive interventions are still needed for cessation even among those who may spontaneously cut down prior to a quit attempt. Future studies of novel smoking cessation interventions may wish to consider investigating scheduled reductions combined with pharmacotherapy as a means of promoting cessation with correctional populations.