Cue-Restricted Smoking as a behavioral adjunct for smoking cessation: Observational sub-analysis of a randomized trial of deep transcranial magnetic stimulation.
Jaqueline R Scholz, Bianca B Bellini, Sara D V Ziotti, Tania O Abe, Debora Arnaut, Rodrigo L Alberto, Marco A Marcolin, Serena Tonstad
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Abstract
Introduction: Cue-Restricted Smoking (CRS) is a behavioral technique for smoking cessation that has shown efficacy as an adjunct to pharmacotherapy. In CRS, individuals limit smoking to a standing position while facing a wall in an isolated environment devoid of sensory stimulation. This study aimed to assess the potential impact of CRS in a randomized trial evaluating deep transcranial magnetic stimulation (dTMS), which failed to show significant treatment effects.
Methods: In a randomized, double-blind, sham-controlled trial evaluating dTMS for smoking cessation, 100 participants were instructed to quit smoking by the end of week 1. None achieved cessation. Only 85 participants remained in the protocol beyond week 1 and received guidance to implement CRS during cravings. Cigarette consumption was monitored through self-report, exhaled carbon monoxide (COex), and plasma cotinine levels. Participants were categorized as: no reduction, additional reduction, or cessation. Joinpoint regression was used to assess longitudinal trends.
Results: The 85 participants (68% male; mean age 49 ± 11.6 years) reported a mean of 31 ± 11.2 years of smoking. Beyond week one, 33% had not reduced their consumption, 8% showed a mild reduction, 43% a moderate reduction, and 15% a significant reduction; none achieved cessation. After CRS, 40% (95% CI: 29.5-51.2) reported further reduction, and 16.5% (95% CI: 9.3-26.1) achieved verified cessation by week 12. Joinpoint analysis confirmed significant decreasing trends in cigarette use and COex among the significant reduction and cessation groups.
Conclusions: CRS was associated with clinically meaningful reductions in smoking and biochemically confirmed cessation. It is a low-cost, scalable technique that does not require intensive training or pharmacotherapy. This approach may be advantageous in low-resource settings. It warrants evaluation in larger randomized trials across diverse populations.
Clinical trial registration: The study is registered on the official website of ClinicalTrials.gov.
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