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The adjusted relative risk for cardiovascular disease after 21 years follow-up was 1.02 (compared with continuing heavy smokers), unlike the benefit seen in quitters (relative risk 0.46) or the positive effect on risk of lung cancer in those who reduced (relative risk 0.66).76 In the third study (475 734 adults), 5.2% of heavy smokers (at least 20 cigarettes per day) reduced to less than 10 cigarettes per day two years later, with little risk reduction after nine years follow-up (adjusted relative risk 0.85 for stroke and 0.92 for coronary heart disease, compared with continuing heavy smokers), in contrast to the beneficial effect in quitters (relative risk 0.70 for stroke and 0.43 for coronary heart disease)77 and the effect on lung cancer in those who reduced (relative risk 0.66).78 These studies indicate that a substantial bias is unlikely to be produced by heavy smokers cutting down, because only a small proportion did so, and that those who reduced consumption did not seem to have much benefit in terms of cardiovascular disease risk

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