Cessation

Most people who smoke want to quit, but quitting smoking is incredibly challenging because nicotine is a highly addictive drug. Therefore, most would-be quitters require multiple attempts to quit successfully. The health benefits of quitting begin almost instantly and improve health at any age, although the health benefits are greater the younger a person is when they quit. On average, smoking causes more than a decade of life lost, but quitting before age 40 can return almost all those years (i.e., reducing a former smoker’s chance of tobacco-related death by 90%).

Tobacco cessation is a cost-effective health care intervention for smokers, but in many countries cessation support is woefully inadequate. Though smokers of any age will benefit from cessation, helping young smokers quit will yield the biggest long-term health and economic benefits. Thus, governments must make cessation a health care priority by increasing its availability and accessibility. One way to do this is by providing cessation services through health care workers. Integrating cessation into key moments when people interact with the health care system is extremely effective (e.g., disease diagnosis, pregnancy, annual routine care, etc.) and builds on the trust that many individuals hold in health care providers. Integrating cessation into existing health infrastructure is also economical. During routine or other visits, health care workers can ask patients if they use tobacco and record this information, advise smokers to stop, and actively direct smokers to supportive resources and/or counseling. Remarkably, most countries do not integrate cessation into basic medical advising, or even help health workers—who serve as important role models—to quit smoking themselves.

Governments can invest in promoting cessation by developing evidence-based national strategies and guidelines and adequately resourcing them. Core interventions include national quitlines, support for cessation counseling (including evidence-based, inexpensive mobile phone text messaging services), making nicotine replacement therapies (NRTs) and cessation medicines more accessible and affordable, and establishing mass media campaigns to promote quitting. Globally, while tens of billions of dollars are being collected in tobacco taxes, too little support is given to helping smokers quit, particularly in lower-HDI countries. However, some progress is being made. In 2017, less than a quarter of countries had a free national quitline, but by 2019 that number had increased to nearly 40%. Still, there is room for improvement, since in 2019 less than a third of countries fully or even partially covered the cost of cessation medicines and/or NRTs.

While roughly three quarters of smokers who quit successfully do so without any pharmaceutical or counseling aid, cessation medications can double the likelihood that someone will quit successfully. This likelihood increases further if the medication is administered in conjunction with counseling. For decades, nicotine replacement therapy (NRT) products have included only a handful of evidence-backed products including transdermal patches, lozenges, chewing gum, sublingual tablets, oral inhalers, and nasal spray. The entrance of e-cigarettes and other novel, often over-the-counter, products to the marketplace has complicated cessation approaches.

While tobacco companies sometimes market these products directly as cessation tools, no regulatory body in the world has authorized them as such, not even the United Kingdom where the National Health Service now openly acknowledges some potential utility for quitting. But the e-cigarette industry’s behavior suggests that its intentions are not focused on quitting; rather the evidence shows that their marketing in most circumstances is aimed squarely at young people who do not use tobacco, not adult smokers struggling to quit. Nonetheless, in some countries, e-cigarettes are a popular way to try to quit.

The scientific evidence on how e-cigarettes compare to NRT as a cessation support method is mixed. For instance, a recent study tracking quitters and would-be quitters shows that e-cigarettes were no more effective than other NRTs, whereas authors of a separate 2021 review of a small number of recent randomized controlled trials were “moderately confident that nicotine e-cigarettes help more people to stop smoking than nicotine replacement therapy or nicotine-free e-cigarettes,” while conceding that “more studies are still needed to confirm this.”

Confidence in this research should be tempered because of the limited number of studies, the difficulties of generalizing to all e-cigarette products in largely unregulated and evolving marketplaces, and widely different contexts in research conditions. Furthermore, many smokers who quit continued to use e-cigarettes, and with the uncertainty around the level of harm of these products (see E-cigarettes & HTPs) many cessation experts worry about the long-term health tradeoffs. With all these uncertainties, many countries have decided to highly regulate these products and they are not included in cessation strategies. There is strong consensus that further rigorous research is warranted.