Promoting smoking cessation through smoking reduction during Ramadana dd_3432 1379..1380Ramadan restricts smoking and leads to reduction. Recent research on reduction has focused upon using nicotine replacement therapy (NRT) as a substitute for missed cigarettes and behavioural approaches have been neglected, despite evidence of efficacy. Ramadan reminds us of the need to harness these natural experiments to enhance smoking reduction and hence cessation.Ramadan, the ninth month of the Islamic calendar, marks the period when Muslims fast during daylight hours to learn patience, humility, sacrifice, self-restraint and, above all, God-consciousness. It is a time of increased devotion to God and spiritual renewal. During the month, Muslims should not eat, drink (any liquid) or smoke from dawn to dusk. In the United Kingdom, there is a national smoking cessation service that has ambitious targets for throughput and a responsibility to reach all ethnic groups. Many public health authorities have used the start of Ramadan as a spur to encourage smoking cessation [1,2], using several lines of reasoning. Enforced abstinence from smoking during daylight will engender withdrawal for many regular smokers [3]. With sustained abstinence withdrawal will subside, but not with continued smoking during darkness, so the period of Ramadan is uncomfortable for many smokers unless they become totally abstinent. Secondly, lapsing during a quit attempt makes achieving prolonged abstinence much less likely [4], and the prohibition against smoking during the day and the absence of others smoking could assist the quit attempt [5]. Thirdly, the element of spiritual renewal could lead to changes in a person's sense of self that might bolster cessation success. Gonzales et al. reported that nine out of 10 smokers in Oregon, United States, had previously believed or currently recognized some higher power [6]. Three-quarters of smokers reported believing that drawing upon spirituality could be helpful when quitting, and the same proportion felt that smoking cessation counsellors should encourage smokers to do so in clinics. This is similar to the treatment of other addictions where discussion of spiritual resources is common, for example, in Alcoholics Anonymous [7].There are, however, potential disadvantages to encouraging abrupt cessation at the start of Ramadan. Chief among these is that few Muslims take the opportunity to attend smoking cessation clinics. It is possible that our current focus on cessation at the expense of the perhaps more achievable target of smoking reduction is alienating those who might otherwise engage. Whether unassisted attempts at cessation are common is not known, and whether they are more successful at this time is also unknown. Furthermore, most supported cessation attempts involve medication, but many Muslims believe that Ramadan precludes oral medication during daylight, meaning that oral nicotine replacement therapy (NRT) is inappropriate and so, perhaps, is varenicline and bupropion. Abstaining from food inc...