Quitting smoking is hard – as difficult as kicking a heroin, cocaine or alcohol addiction – and so is making the commitment to quit. To date, U.S. guidelines have advocated for quitting abruptly, but new research reported in the February 17, 2015 Journal of the American Medical Association provides strong evidence for a remarkably effective alternative: using a nicotine addiction medication combined with gradual smoking reduction before quitting.

“The ‘just do it’ attitude can be counterproductive in smoking,” says University of Vermont Professor of Psychiatry John Hughes, M.D., a coauthor on the study who has been researching smoking cessation strategies for more than 30 years. “We are trying to figure out the ‘baby steps’ to quitting,” he adds. Reduction – supported with varenicline, which blocks the effects of addictive nicotine – appears to offer a promising path.

The JAMA study, led by Jon O. Ebbert, M.D., M.Sc., of the Mayo Clinic in Rochester, Minn., and conducted at 61 centers in 10 countries, examined cigarette smokers who were not willing or able to quit smoking immediately (i.e., in the next month), but were willing to reduce smoking with the goal of quitting in the future (i.e., in the next three months). A total of 1,510 cigarette smokers were randomly assigned to take either varenicline (also known as Chantix) or placebo for 24 weeks while trying to smoke 50 percent less cigarettes by the end of four weeks, 75 percent less cigarettes by eight weeks, and a quit attempt by 12 weeks. Hughes had previously demonstrated in a small study that varenicline could be used this way, but the current study is a much better test. UVM was not one of the centers in this particular study.

The study’s authors report that use of varenicline for 24 weeks compared with placebo significantly increased smoking cessation rates at the end of treatment, and also at one year. Specifically, the varenicline group quadrupled continuous abstinence rates during weeks 15 through 24 than the placebo group (32.1 percent vs. 6.9 percent).

In addition, the researchers found that after eight weeks, 26.3 percent of participants in the varenicline group reduced smoking by 75 percent or more from baseline or abstained compared with 15.1 percent participants in the placebo group.

Based on these findings and previous research, “we’re thinking more and more about giving people medication and letting them choose when to quit,” Hughes says.

Currently in the U.S., varenicline is only prescribed to patients following an abrupt quitting approach, but, according to Hughes, the European Union has an indication for using several medications as an adjunct to reducing to quit. “We don’t have that indication for any smoking cessation product here,” he says.

“The U.S. Public Health Service and other guidelines recommend smokers set a quit date in the near future and quit abruptly. However, many smokers may be unwilling to commit to a quit date at a clinic visit. Because most clinicians are likely to see smokers at times when a quit date in the next month is not planned, the current study indicates that prescription of varenicline with a recommendation to reduce the number of cigarettes smoked per day with the eventual goal of quitting could be a useful therapeutic option for this population of smokers. The approach of reduction with the goal of quitting increases the options for a clinician caring for a smoker,” the authors write.

The study was funded by Pfizer.