Hard Truths About Smoking Cessation

I’ve worked in tobacco control, in one way or another, since 2001. Over the past 20+ years, I have been involved in several major smoking cessation initiatives. Among these, I served on the team that developed “Ohio Quits,” an integrated network of cessation modalities that included hospital-based treatment clinics, community quit programs and a quitline. Unfortunately, Ohio ended that program when it redirected and securitized payments from the tobacco industry intended to compensate the state in perpetuity for smoking-related health costs.

I also directed the NYS Tobacco Control Program which emphasized health systems interventions and clinician engagement to accelerate smoking cessation and better address smoking-related disparities. Unfortunately, New York state government made a 50% cut to that program’s funding which substantially weakened our cessation infrastructure. These drastic cuts began during a period in which tobacco control advocates helped increase the state’s cigarette excise tax by $1.60 per pack, bringing in several hundred million dollars in additional tax revenue per year.

Like many of you, I have relatives who died from smoking-related illnesses and who had tried to quit smoking on many occasions. With both my experience in tobacco control and those family members in mind, I offer what I believe are “5 Truths” about smoking cessation. By acknowledging the realities of smoking cessation, we can develop a much more effective strategy to finally end cigarette smoking in the United States.

First Truth - Tobacco Control Has Had a Substantial and Essential Impact

In a nutshell, tobacco control in the U.S. has created an environment in which cigarette smokers want to quit. Through education about the harmful effects of smoking, campaigns that denormalize smoking, increasing the price of cigarettes and restricting locations in which smoking can occur, millions more cigarette users have been motivated to make quit attempts. Today, roughly 2-in-3 adults who smoke want to quit and roughly half of adults who smoke made a serious attempt to quit in the past year. In addition, tobacco control has implemented smoking cessation interventions, such as quitlines and quit programs, and advocated for increased access to evidence-based smoking cessation therapies. There is no doubt that, over its history, tobacco control in the United States has helped millions of people quit smoking.

Second Truth – Tobacco Control’s Impact Has Been Insufficient

Despite the strong desire to quit, the success rate for people who try to quit smoking remains far too low. Among the millions of adults who tried to quit smoking in 2022, less than 10 percent were successful. Successful quitting is related to socioeconomic status and other factors and, today, adult smoking is concentrated among those with lower-socioeconomic backgrounds, the LGBTQ+ community and those with mental health comorbidities. In addition, state-level variation in tobacco control programming has contributed to geographic inequities in accessing cessation services. Even in states which have made substantial investments in smoking cessation, such as my experiences in Ohio and New York, state governments can abruptly cut program funding and eliminate or significantly reduce these services.

Today, roughly 28 million adults in the United States smoke cigarettes. Most want to quit. Roughly half will try to quit next year. More must be done to help them.

Third Truth – Lives Are Lost While Waiting for "Acceptable" Breakthroughs

Many in public health prefer that expansion of and enhancements to existing tobacco control approaches and new FDA-authorized smoking cessation therapies will be sufficient to end smoking in the United States. Unfortunately, it's hard to imagine a significant expansion of public health smoking cessation services in the near future. I do not anticipate increases in federal or state tobacco control funding; in fact, we are likely to see continued reductions in such funding. Approvals of new smoking cessation therapies are not imminent, and FDA’s Center for Drug Research and Evaluation recently called for additional safety studies for the promising therapeutic cytisine. Researchers have estimated that a year-long delay in FDA’s approval of cytisine would prevent 71,000 people from quitting smoking and reduce aggregate population-level life expectancy by 10,000 years.

The unfortunate human cost of the status quo for smoking cessation is the continued gradual and inequitable reduction in smoking-related diseases and death.

Fourth Truth – Many Former Smokers Are Using E-Cigarettes

Based on estimates by the CDC, there were roughly 4.4 million former cigarette smokers who used e-cigarettes in 2021. In addition, there is an increasing body of evidence that e-cigarettes are at least as effective as NRT in supporting smoking cessation. Other than older Americans, rates of adult cigarette use are declining, and rates of adult e-cigarette use are increasing in the U.S. Based on actual trends in adult tobacco use, there is a very strong likelihood that the final steps toward a smoke-free society will be taken by millions of people who quit smoking using noncombustible commercial tobacco products because nothing else has helped them quit. By acknowledging this reality, the tobacco control community can help ensure this transition occurs in a way that maximizes public health benefits and minimizes risks for kids and adults with no history of cigarette smoking.

Fifth Truth – Ending Cigarette Smoking Should Be Our Primary Public Health Objective

U.S. Surgeon General Vivek Murthy recently reminded us that cigarette smoking-attributable illness causes 490,000 deaths (roughly 1-in-5 of all deaths) in the United States each year. Combustible cigarettes specifically, not commercial tobacco products generally, are the leading cause of preventable death in the United States. It is clear that, regardless of how public health entities view the ideal “end state” for tobacco use in our society, ending combustible tobacco use is an essential step for dramatically improving public health. Anyone concerned with public health should demand the creation of a realistic, national strategy focused on helping many more people quit smoking cigarettes.

Ending Smoking and Saving Lives

It is possible to end the epidemic of disease and death caused by cigarette smoking and I believe we’ve been dealt a strong hand to do so. Notably, most people who smoke want to quit and will try, again, to do so; public health has strong capacity for advocacy and education that could dramatically accelerate reductions in cigarette smoking; and federal regulation can help ensure any new noncombustible tobacco products meet the FDA’s public health standard.

Let’s acknowledge the hard truths about smoking cessation, embrace the potential we have to help more people quit smoking, and develop a pragmatic strategy that will eliminate the disease and death caused by combustible cigarettes.