Tobacco use is a major cause of cardiovascular, respiratory and oncological disease. Quitting smoking significantly benefits health, but for highly dependent smokers, unable to overcome their nicotine dependence, the concept of smoking reduction as a method of harm reduction is gaining ground. The University Hospital of Basle, Switzerland, has run double-blind, placebo-controlled smoking cessation and smoking reduction studies: the CEASE trial evaluated the efficacy of the nicotine patch in achieving abstinence, and the Rosette study is evaluating the efficacy and tolerability of the nicotine oral inhaler in smokers who do not wish to quit. Smokers were instructed either to quit smoking (CEASE) or to reduce cigarette consumption by > 50% (Rosette). In both studies, success rates for active treatment versus placebo at 4 months demonstrated that nicotine replacement therapy (NRT) is effective in achieving both smoking cessation and reduction. Current approaches to smoking cessation and reduction at our clinic are discussed. Combination NRT rather than monotherapy is commonly used to achieve both smoking reduction and cessation. Treatment appears to be most effective if subjects are allowed to select their preferred NRT product. There are clear differences in patient populations aiming to quit or reduce, the cessation population being more motivated. Smoking cessation remains the ultimate aim but, if unfeasible, a significant reduction in cigarette consumption is a valid goal.