Smoking Cessation

A Report of the Surgeon General

Executive Summary

U.S. Department of Health and Human Services

Smoking Cessation

A Report of the Surgeon General

Executive Summary

2020

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Office of the Surgeon General

Rockville, MD
Suggested Citation

U.S. Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General—

Executive Summary. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease 

Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office 

on Smoking and Health, 2020.

For more information

For more information about the Surgeon General’s report, or to download copies of this document, 

visit www.surgeongeneral.gov.

To order copies of this document, go to www.cdc.gov/tobacco and click on Publications Catalog or call 

1-800-CDC-INFO (1-800-232-4636); TTY: 1-888-232-6348.

Use of trade names is for identification only and does not constitute endorsement by the Department 

of Health and Human Services. Any recommendations expressed by nongovernmental individuals or 

organizations do not necessarily represent the views or opinions of the U.S. Department of Health 

and Human Services.
iii

Message from Alex M. Azar II

Secretary, U.S. Department of Health and Human Services

Throughout its history, the U.S. Department of Health and Human Services (USDHHS) has led 

efforts to prevent and reduce the devastating effects of tobacco use, especially the use of combustible tobacco products, as part of its mission to enhance and protect the health and well-being of all 

Americans. USDHHS has provided critical support in the fields of research and evaluation, program and 

policy development, public information and education, regulatory activities, systems-level change and 

management, and clinical practices that has contributed to a dramatic 67% decline in cigarette smoking 

among U.S. adults since 1965. Support from USDHHS has helped medical and healthcare organizations, government agencies at all levels, and nongovernmental partners create and sustain programs 

that prevent initiation; help tobacco product users quit; and foster healthy, smokefree environments.

This report is the latest of a longstanding tradition of tobacco prevention and control efforts 

by USDHHS. Our work includes a comprehensive tobacco control strategic action plan, Ending the 

Tobacco Epidemic, and coordination of tobacco control efforts with related efforts by other federal agencies through the Interagency Committee on Smoking and Health. Reports such as this one from the 

U.S. Surgeon General give the latest data on tobacco and health to scientists, healthcare professionals, 

and the public. Research leadership and grant funding through USDHHS’s National Institutes of Health 

contribute to growing knowledge of effective tobacco control strategies and smoking cessation tools. 

The National Tobacco Control Program, led by the Centers for Disease Control and Prevention (CDC), 

ensures that these strategies and tools are readily available to state, local, tribal, and territorial public 

health programs, as well as to partners serving a variety of populations that are disproportionately 

affected by tobacco use. The U.S. Food and Drug Administration (FDA) regulates the manufacturing, 

marketing, and sale of tobacco products. Medicare and Medicaid provide smoking cessation tools and 

support to millions of Americans. Multiple public information campaigns, such as CDC’s Tips From

Former Smokers and FDA’s Every Try Counts, educate Americans about the significant health risks 

from smoking and the importance of quitting. Additionally, many agencies in USDHHS provide direct 

assistance to smokers, including the National Cancer Institute through its Smokefree.gov initiative 

(https://smokefree.gov), and national quitline portal, 1-800-QUIT-NOW.

These and other important efforts are critical to improving the nation’s public health. Smoking 

kills nearly half a million Americans every year, and millions more live with serious chronic diseases 

caused by smoking. We know that comprehensive interventions at all levels of government and by 

partners throughout the public health community are extremely effective at preventing and reducing 

tobacco use. We remain committed to ending the tobacco use epidemic in the United States.

v

Foreword

Tobacco use remains the number one cause of preventable disease, disability, and death in the 

United States. Approximately 34 million American adults currently smoke cigarettes, with most of 

them smoking daily. Nearly all adult smokers have been smoking since adolescence. More than twothirds of smokers say they want to quit, and every day thousands try to quit. But because the nicotine 

in cigarettes is highly addictive, it takes most smokers multiple attempts to quit for good.

Today, we know much more about the science of quitting than ever before. Research shows that 

smokers who use evidence-based tools to help them quit are more likely to succeed than those who do not 

use such tools, and that using a combination of these tools—for example, calling 1-800-QUIT-NOW and 

using nicotine replacement therapy, such as the nicotine patch or gum or a prescription medication—

raises success rates even higher. Studies also show that policies that prohibit smoking in indoor public 

places and work spaces and that increase the price of tobacco products promote smoking cessation.

This Surgeon General’s report

• Examines the effectiveness of various smoking cessation tools and resources;

• Reviews the health effects of smoking and catalogues the improvements to health that can occur 

when smokers quit;

• Highlights important new data on populations in which the prevalence of smoking is high and quit 

rates are low; and

• Identifies gaps in the availability and utilization of programs, policies, and resources that can 

improve cessation rates and help smokers quit.

Although the benefits of quitting are greater the earlier in life that an individual quits, this report 

confirms that it is never too late to quit smoking. Even persons who have smoked for many years or who 

have smoked heavily can realize health and financial benefits from quitting smoking.

The financial toll of smoking is substantial. Each year in the United States, annual healthcare 

spending attributed to smoking exceeds $170 billion. Measured against these numbers, comprehensive 

tobacco prevention and control strategies are extremely cost-effective investments that yield significant 

returns. For example, the first year of CDC’s Tips From Former Smokers national campaign prevented 

thousands of premature deaths in the United States, costing less than $500 for every smoker who quit.

We know what works to prevent and reduce tobacco use, including how to best help smokers quit 

for good. Putting this knowledge into action prevents disease, saves lives, and improves the quality of 

life for all Americans. At CDC, we remain committed to supporting the longstanding national effort to 

end the tobacco use epidemic and provide all Americans with the opportunity to live tobacco-free.

Robert R. Redfield, M.D.

Director

Centers for Disease Control and Prevention

vii

Preface

from the Surgeon General

One of the most significant public health successes in modern U.S. history has been the reduction 

in smoking that has occurred during the past half century. Today, the prevalence of cigarette smoking 

among American adults is at an all-time low, 14%. Although this overall achievement is a source of 

pride, there is still more work to be done. Today, 16 million Americans are living with a smoking-related 

disease. In addition to the human costs, smoking places a significant financial burden on Americans, 

as smoking-attributable healthcare spending exceeds $170 billion per year.

Research, medical advances, and years of documented experience have given us many tools to 

tackle the tobacco use epidemic in this country. Although quitting smoking can be a difficult process for many smokers, most say they want to quit, and every year more than half make a serious quit 

attempt. But only a small portion of smokers who try to quit succeed, and only a small portion use any 

of the tested and proven aids that will significantly increase their chances of success. This Surgeon 

General’s report on smoking cessation, the 34th report on smoking and health since 1964, examines 

the most current research on this important issue, identifies barriers to continued success in reducing 

the prevalence of smoking across all populations, and summarizes evidence-based solutions that can 

help to eliminate those barriers.

Clinical interventions for smoking cessation are critical if we are to achieve our goal of eliminating the devastating effects of smoking on public health. Primary care physicians, nurses, pharmacists, and other providers in all medical disciplines and in all healthcare environments should take 

advantage of these opportunities to inform and encourage smokers to quit. Doing so could enable half 

a million smokers to quit each year.

As a physician, I am acutely aware of the many pressing demands that healthcare providers must 

address to deliver the highest quality care possible to their patients. At the same time, the evidence in 

this report clearly points to the tremendous positive impact that healthcare professionals can have on 

the health and quality of life of their patients and on the public health of our nation—just by helping 

smokers to quit.

But healthcare professionals alone cannot solve this public health challenge. Everyone has a role 

in helping to continue to reduce the burden of tobacco use on our society. It is critical that clinical 

interventions be adopted alongside broader efforts at the health system and population levels to promote and cultivate successful cessation and tobacco-free norms. Even today, with all the gains that have 

been made over the past few decades, smoking remains the single largest cause of preventable disease 

and death in the United States. As a nation, we can and must spare no effort to reduce the completely 

preventable health and financial costs that tobacco smoking has on society.

Jerome M. Adams, M.D., M.P.H.

Vice Admiral, U.S. Public Health Service

Surgeon General of the United States

Executive Summary 1

Smoking Cessation

Overview

Tobacco smoking is the leading cause of preventable 

disease, disability, and death in the United States (U.S. 

Department of Health and Human Services [USDHHS] 

2014). Smoking harms nearly every organ in the body and 

costs the United States billions of dollars in direct medical 

costs each year (USDHHS 2014). Although considerable 

progress has been made in reducing cigarette smoking 

since the first U.S. Surgeon General’s report was released 

in 1964 (USDHHS 2014), in 2018, 13.7% of U.S. adults 

(34.2 million people) were still current cigarette smokers 

(Creamer et al. 2019). One of the main reasons smokers 

keep smoking is nicotine (USDHHS 1988). Nicotine, 

a  drug found naturally in the tobacco plant, is highly 

addictive, as with such drugs as cocaine and heroin; activates the brain’s reward circuits; and reinforces repeated 

nicotine exposure (USDHHS 1988, 2010, 2014; National 

Institute on Drug Abuse 2018). 

The majority of cigarette smokers (68%) want to quit 

smoking completely (Babb et al. 2017). The 1990 Surgeon 

General’s report, The Health Benefits of Smoking Cessation, 

was the last Surgeon General’s report to focus on current research on smoking cessation and to predominantly 

review the health benefits of quitting smoking (USDHHS 

1990). Because of limited data at that time, the 1990 report 

did not review the determinants, processes, or outcomes 

of attempts at smoking cessation. Pharmacotherapy for 

smoking cessation was not introduced until the 1980s. 

Additionally, behavioral and other counseling approaches 

were slow to develop and not widely available at the time 

of the 1990 report because few were covered under health 

insurance, and programs such as group counseling sessions were hard for smokers to access, even by those who 

were motivated to quit (Fiore et al. 1990).

The purpose of this report is to update and expand 

the 1990 Surgeon General’s report based on new scientific 

evidence on smoking cessation. Since 1990, the scientific 

literature has expanded greatly on the determinants and 

processes of smoking cessation, informing the development of interventions that promote cessation and help 

smokers quit (Fiore et al. 2008; Schlam and Baker 2013). 

This knowledge and other major developments have transformed the landscape of smoking cessation in the United 

States. This report summarizes this enhanced knowledge 

and specifically reviews patterns and trends of smoking 

cessation; biologic mechanisms; various health benefits; 

overall morbidity, mortality, and economic benefits; interventions; and policies that promote smoking cessation.

From 1965 to 2017, the prevalence of current 

smoking declined from 52.0% to 15.8% (relative percent change: 69.6%) among men and from 34.1% to 

12.2% (relative percent change: 64.2%) among women 

(Figure ES.1). These declines have been attributed, in part, 

to progress made in smoking cessation since the 1960s, 

which has continued since the 1990 Surgeon General’s 

report. Specifically, clinical, scientific, and public health 

communities have increasingly embraced and acted upon 

the concept of tobacco use and dependence as a health 

condition that can benefit from treatment in various forms 

and levels of intensity. Accordingly, a considerable range of 

effective pharmacologic and behavioral smoking cessation 

treatment options are now available. As of October 16, 2019, 

the U.S. Food and Drug Administration (FDA) has approved 

five nicotine replacement therapies (NRTs) and two nonnicotine oral medications to help smokers quit, and the 

use of these treatments has expanded, including stronger 

integration with counseling support (Fiore et al. 2008).

In addition, the reach of smoking cessation interventions has increased substantially since 1990 with the 

emergence of innovative, population-level interventions 

and policies that motivate smokers to quit and raise awareness of the health benefits of smoking cessation (McAfee 

et al. 2013). This includes policies, such as comprehensive 

smokefree laws, that have been shown to promote cessation at the population level in addition to reducing exposure to secondhand smoke (USDHHS 2014). The development and subsequent expansion of telephone call centers 

(“quitlines”), mobile phone technologies, Internet-based 

applications, and other innovations have created novel platforms to provide behavioral and pharmacologic smoking 

cessation treatments (Ghorai et al. 2014). However, the 

continued diversification of the tobacco product landscape 

could have several different potential impacts, ranging 

from accelerating the rates of complete cessation among 

adult smokers to erasing progress in reducing all forms 

of use of tobacco products, especially among youth and 

young adults. For example, the increasing availability and 

rapidly increasing use of novel tobacco products, most 

notably e-cigarettes, raise questions about the potential 

impact that such products could have on efforts to eliminate disease and death caused by tobacco use at the individual and population levels. Therefore, when considering 

the impact of e-cigarettes on public health, it is critical to 

evaluate their effects on adults and youth.

Collectively, the changes cited in this report provide new opportunities and challenges for understanding 

and promoting smoking cessation in the United States. 

However, the extensive body of evidence-based clinical, 

health system, and population-based tobacco prevention, control, and cessation strategies that are outlined 

in this report are a necessary but insufficient means to 
A Report of the Surgeon General

2 Executive Summary

end the tobacco epidemic. Reaching the finish line will 

require coordination across federal government agencies 

and other government and non-government stakeholders 

at the national, state, and local levels. To achieve success, 

we must work together to maximize resources and coordinate efforts across a wide range of stakeholders.

Figure ES.1 Trends in prevalence (%) of current and former cigarette smoking among adults 18 years of age and 

older, by sex; National Health Interview Survey (NHIS) 1965–2017; United States

Source: NHIS, National Center for Health Statistics, public use data, 1965–2017.

Note: From 1965 to 2017, data were reported for the following years: 1965, 1966, 1970, 1974, 1976–1980, 1983, 1985, 1987, 1988, 

1990–1995, and 1997–2017.

Major Conclusions of the Report

1. Smoking cessation is beneficial at any age. Smoking 

cessation improves health status and enhances 

quality of life.

2. Smoking cessation reduces the risk of premature death and can add as much as a decade to life 

expectancy. 

3. Smoking places a substantial financial burden on 

smokers, healthcare systems, and society. Smoking 

cessation reduces this burden, including smokingattributable healthcare expenditures. 

4. Smoking cessation reduces risk for many adverse 

health effects, including reproductive health outcomes, cardiovascular diseases, chronic obstructive 

pulmonary disease, and cancer. Quitting smoking 

is also beneficial to those who have been diagnosed 

with heart disease and chronic obstructive pulmonary disease.

5. More than three out of five U.S. adults who have ever 

smoked cigarettes have quit. Although a majority of 

cigarette smokers make a quit attempt each year, less 

than one-third use cessation medications approved 

by the U.S. Food and Drug Administration or behavioral counseling to support quit attempts. 

6. Considerable disparities exist in the prevalence of 

smoking across the U.S. population, with higher prevalence in some subgroups. Similarly, the prevalence of 

key indicators of smoking cessation—quit attempts, 

receiving advice to quit from a health professional, 

and using cessation therapies—also varies across the 

population, with lower prevalence in some subgroups. 

7. Smoking cessation medications approved by the 

U.S. Food and Drug Administration and behavioral 

counseling are cost-effective cessation strategies. 

Cessation medications approved by the U.S. Food 

and Drug Administration and behavioral counseling 
Executive Summary 3

Smoking Cessation

increase the likelihood of successfully quitting 

smoking, particularly when used in combination. 

Using combinations of nicotine replacement therapies can further increase the likelihood of quitting. 

8. Insurance coverage for smoking cessation treatment that is comprehensive, barrier-free, and widely 

promoted increases the use of these treatment services, leads to higher rates of successful quitting, 

and is cost-effective.

9. E-cigarettes, a continually changing and heterogeneous group of products, are used in a variety 

of  ways. Consequently, it is difficult to make generalizations about efficacy for cessation based on 

clinical trials involving a particular e-cigarette, 

and there is presently inadequate evidence to conclude that e-cigarettes, in general, increase smoking 

cessation.

10. Smoking cessation can be increased by raising the 

price of cigarettes, adopting comprehensive smokefree policies, implementing mass media campaigns, 

requiring pictorial health warnings, and maintaining comprehensive statewide tobacco control 

programs.

Preparation of the Report

This Surgeon General’s report was prepared by the 

Office on Smoking and Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for 

Disease Control and Prevention (CDC), which is part of 

USDHHS. This report was compiled using a longstanding, 

peer-reviewed, balanced, and comprehensive process 

designed to safeguard the scientific rigor and practical relevance from influences that could adversely affect impartiality (King et al. 2018). This process helps to ensure that 

the report’s conclusions are defined by the evidence, rather 

than the opinions of the authors and editors. In brief, under 

the leadership of a senior scientific editorial team, 32 experts 

wrote the initial drafts of the chapters. The experts were 

selected for their knowledge of the topics addressed. These 

contributions, which are summarized in Chapters  1–7, 

were evaluated by 46 peer reviewers. After this initial stage 

of peer review, more than 20 senior scientists and other 

experts examined the scientific integrity of the entire manuscript as part of a second stage of peer review. After each 

round of peer review, the report’s scientific editors revised 

each draft based on reviewers’ comments. Chapter 8, which 

summarizes and is founded upon the preceding content 

in the report, was written by the senior scientific editorial team once the content in Chapters 1–7 completed peer 

review. Subsequently, the report was reviewed by various 

institutes and agencies in the U.S. Government, including 

USDHHS. Throughout the review process, the content of 

each chapter was revised to include studies and information 

that were not available when the chapters were first drafted; 

updates were made until shortly before the report was submitted for publication. These updates reflect the full scope 

of identified evidence, including new findings that confirm, 

refute, or refine the initial content. Conclusions are based 

on the preponderance and quality of scientific evidence.

Scientific Basis of the Report

The statements and conclusions throughout this 

report are based on an extensive review of the existing scientific literature. Thus, the report primarily focuses on cessation in the context of adults because this is the population 

for which the preponderance of scientific literature exists 

on this topic; however, data on youth and young adults 

are also presented, when available. The report primarily 

cites peer-reviewed journal articles, including reviews that 

integrate findings from numerous studies and books that 

were published between 2000 and 2018, which reflects the 

period after the last Surgeon General’s report on the topic 

of cessation. This report also refers, on occasion, to unpublished research, such as presentations at professional meetings, personal communications from researchers, and 

information available in various media. These references 

are used when acknowledged by the editors and reviewers 

as being scientifically valid and reliable, and a critical addition to the emerging literature on a topic. Throughout the 

writing and review process, highest priority was given to 

peer-reviewed, scientific research that is free from tobacco 

industry interests. As noted in the 2014 Surgeon General’s 

report, the tobacco industry has a well-documented record 

of manipulating scientific information about the extent of 

the harms from cigarette smoking (USDHHS 2014).

Following the model of the 1964 report, this 

Surgeon General’s report includes comprehensive compilations of the evidence on smoking cessation. The evidence is analyzed to identify causal associations according 
A Report of the Surgeon General

4 Executive Summary

to enunciated principles, sometimes referred to as the 

“Surgeon General’s criteria” or the “Hill” criteria (after Sir 

Austin Bradford Hill) for causality. The criteria, offered in 

Chapter 3 of the 1964 report, included

• Consistency of the association,

• Strength of the association,

• Specificity of the association, 

• Temporal relationship of the association, and 

• Coherence of the association (U.S. Department of 

Health, Education, and Welfare [USDHEW] 1964, 

p. 20). 

In the 2004 Surgeon General’s report (USDHHS 

2004), the framework for interpreting evidence on smoking 

and health was revisited in depth for the first time since 

the 1964 report. The 2004 report provided a four-level 

hierarchy of categories for interpreting evidence, and this 

current report follows the same model: 

a. “Evidence is sufficient to infer a causal relationship.

b. Evidence is suggestive but not sufficient to infer a 

causal relationship.

c. Evidence is inadequate to infer the presence or 

absence of a causal relationship (which encompasses 

evidence that is sparse, of poor quality, or conflicting).

d. Evidence is suggestive of no causal relationship” 

(USDHHS 2004, p. 18).

Answers to several questions helped to guide judgment toward these categories: 

• Do multiple high-quality studies show a consistent 

association between smoking and disease?

• Are the measured effects large enough and statistically strong?

• Does the evidence show that smoking occurs before 

the disease occurs (a temporal association)?

• Is the relationship between smoking and disease 

coherent or plausible in terms of known scientific 

principles, biologic mechanisms, and observed patterns of disease?

• Is there a dose-response relationship between smoking 

and disease?

• Is the risk of disease reduced after quitting smoking?

The categories acknowledge that evidence can be 

“suggestive but not sufficient” to infer a causal relationship, and the categories allow for evidence that is “suggestive of no causal relationship.” This framework also 

separates conclusions regarding causality from the implications of such conclusions. Inference is sharply and 

completely separated from policy or research implications of the conclusions, thus adhering to the approach 

established in the 1964 report. However, consistent with 

past Surgeon General’s reports on tobacco, conclusions 

are not limited to just causal determinations and frequently include recommendations for research, policies, 

or other actions. 

Chapter Summaries and Conclusions

Chapter 2: Patterns of Smoking 

Cessation Among U.S. Adults, 

Young Adults, and Youth

Chapter 2 documents key patterns and trends in 

cigarette smoking cessation in the United States among 

adults overall (persons 18 years of age and older), young 

adults (18–24 years of age), and youth (12–17 years of 

age). The chapter also reviews the changing demographic 

and smoking-related characteristics of cigarette smokers, 

with a focus on how these changes may influence future 

trends in cessation. 

This chapter also describes persistent disparities in 

cessation by age, race/ethnicity, level of education, type of 

health insurance, and other demographic characteristics. 

The chapter highlights trends and recent findings for several different measures, including the quit ratio (the proportion of ever smokers who are former smokers); recent 

successful cessation; past-year quit attempts; interest in 

quitting; receipt of cessation advice from healthcare professionals; and use of effective cessation strategies, such as 

behavioral counseling and medication. As with previous 

Surgeon General’s reports, the chapter focuses primarily 

on cigarette smoking (USDHHS 1990, 2014); however, 

given the shifting patterns of tobacco product use in the 
Executive Summary 5

Smoking Cessation

United States, it also touches on cessation as it relates to 

all tobacco products.

Conclusions

1. In the United States, more than three out of every 

five adults who were ever cigarette smokers have 

quit smoking. 

2. Past-year quit attempts and recent and longer term 

cessation have increased over the past 2 decades 

among adult cigarette smokers.

3. Marked disparities in cessation behaviors, such 

as making a past-year quit attempt and achieving 

recent successful cessation, persist across certain 

population subgroups defined by educational attainment, poverty status, age, health insurance status, 

race/ethnicity, and geography.

4. Advice from health professionals to quit smoking has 

increased since 2000; however, four out of every nine 

adult cigarette smokers who saw a health professional 

during the past year did not receive advice to quit.

5. Use of evidence-based cessation counseling and/or 

medications has increased among adult cigarette 

smokers since 2000; however, more than two-thirds 

of adult cigarette smokers who tried to quit during 

the past year did not use evidence-based treatment.

6. A large proportion of adult smokers report using 

non-evidence-based approaches when trying to quit 

smoking, such as switching to other tobacco products.

Chapter 3: New Biological Insights 

into Smoking Cessation 

Chapter 3 focuses on how biology can influence smoking cessation and reviews four areas of intensive research since the publication of the 2010 Surgeon 

General’s report: (1) cell and molecular biology of nicotine addiction; (2) vaccines and other immunotherapies 

as treatments for tobacco addiction; (3) insights into 

smoking cessation from the field of neurobiology; and 

(4) genetic studies of smoking phenotypes.

The biological mechanisms underlying nicotine addiction continue to be a subject of great research 

interest, and several promising pharmacotherapeutic 

targets have emerged. For example, acquisition of basic 

knowledge about the function of nicotinic acetylcholine 

receptors (nAChRs) led to the development of targeted 

smoking cessation medications currently in use, and 

research would benefit from an additional understanding 

of molecular mechanisms (USDHHS 2010). The 2010 

Surgeon General’s report, How Tobacco Smoke Causes 

Disease—The Biology and Behavioral Basis for SmokingAttributable Disease, described the pharmacokinetics of 

nicotine, the behavioral pharmacology of nicotine addiction, and the known genotypes and receptor subtypes that 

contribute to nicotine addiction (USDHHS 2010). 

Conclusions

1. The evidence is suggestive but not sufficient to infer 

that increasing glutamate transport can alleviate 

nicotine withdrawal symptoms and prevent relapse. 

2. The evidence is suggestive but not sufficient to infer 

that neuropeptide systems play a role in multiple 

stages of the nicotine addiction process, and that 

modulating the function of certain neuropeptides 

can reduce smoking behavior in humans.

3. The evidence is suggestive but not sufficient to 

infer that targeting the habenulo-interpeduncular 

pathway with agents that increase the aversive properties of nicotine are a useful therapeutic target for 

smoking cessation. 

4. The evidence is suggestive but not sufficient to infer 

that vaccines generating adequate levels of nicotinespecific antibodies can block the addictive effects of 

nicotine and aid smoking cessation.

5. The evidence is suggestive but not sufficient to infer 

that dysregulated brain circuits, including prefrontal 

and cingulate cortical regions and their connections 

with various striatal and insula loci, can serve as 

novel therapeutic targets for smoking cessation.

6. The evidence is suggestive but not sufficient to infer 

that the effectiveness of nicotine replacement therapy 

may vary across specific genotype groups.

Chapter 4: The Health Benefits of 

Smoking Cessation

Chapter 4 reviews the findings on disease risks from 

smoking and how these risks change after smoking cessation for major types of chronic diseases, including 

cancer, the cardiovascular and respiratory systems, and 

a wide range of reproductive outcomes. The more recent 

studies expand the observational evidence documenting 
A Report of the Surgeon General

6 Executive Summary

the benefits of smoking cessation and provide insights into 

the mechanisms underlying these benefits. The review of 

smoking cessation and reproductive outcomes documents 

health benefits of maternal smoking cessation across all 

phases of reproduction, from preconception to birth and 

also for male reproductive health.

This chapter also addresses the clinically relevant 

benefits of cessation for mitigating the effects of diseases, particularly in persons with cancer and coronary 

heart disease. This general topic received mention in previous Surgeon General’s reports (USDHHS 1982, 1983, 

1990, 2004), and the consequences of smoking following 

a diagnosis of cancer received specific attention in the 

2014 Surgeon General’s report, leading to a conclusion 

that cigarette smoking has adverse causal effects on persons already diagnosed with cancer (USDHHS 2014). This 

chapter also reviews cessation and cardiovascular disease 

and the implications of cessation for the natural history of 

chronic obstructive pulmonary disease. 

Conclusions

Cancer

1. The evidence is sufficient to infer that smoking 

cessation reduces the risk of lung cancer. 

2. The evidence is sufficient to infer that smoking 

cessation reduces the risk of laryngeal cancer. 

3. The evidence is sufficient to infer that smoking 

cessation reduces the risk of cancers of the oral 

cavity and pharynx.

4. The evidence is sufficient to infer that smoking 

cessation reduces the risk of esophageal cancer. 

5. The evidence is sufficient to infer that smoking 

cessation reduces the risk of pancreatic cancer.

6. The evidence is sufficient to infer that smoking 

cessation reduces the risk of bladder cancer. 

7. The evidence is sufficient to infer that smoking 

cessation reduces the risk of stomach cancer.

8. The evidence is sufficient to infer that smoking 

cessation reduces the risk of colorectal cancer.

9. The evidence is sufficient to infer that smoking 

cessation reduces the risk of liver cancer.

10. The evidence is sufficient to infer that smoking 

cessation reduces the risk of cervical cancer.

11. The evidence is sufficient to infer that smoking 

cessation reduces the risk of kidney cancer.

12. The evidence is sufficient to infer that smoking 

cessation reduces the risk of acute myeloid leukemia.

13. The evidence is sufficient to infer that the relative 

risk of lung cancer decreases steadily after smoking 

cessation compared with the risk for persons continuing to smoke, with risk decreasing to half that 

of continuing smokers approximately 10–15 years 

after smoking cessation and decreasing further with 

continued cessation. 

Smoking Cessation After a Cancer Diagnosis

1. The evidence is suggestive but not sufficient to infer 

a causal relationship between smoking cessation 

and improved all-cause mortality in cancer patients 

who are current smokers at the time of a cancer 

diagnosis.

Cardiovascular Disease

1. The evidence is sufficient to infer that smoking 

cessation reduces levels of markers of inflammation and hypercoagulability and leads to rapid 

improvement in the level of high-density lipoprotein cholesterol.

2. The evidence is sufficient to infer that smoking cessation leads to a reduction in the development of 

subclinical atherosclerosis, and that progression 

slows as time since cessation lengthens. 

3. The evidence is sufficient to infer that smoking cessation reduces the risk of cardiovascular morbidity 

and mortality and the burden of disease from cardiovascular disease.

4. The evidence is sufficient to infer that the relative risk of coronary heart disease among former 

smokers compared with never smokers falls rapidly 

after cessation and then declines more slowly. 

5. The evidence is sufficient to infer that smoking cessation reduces the risk of stroke morbidity and mortality.

6. The evidence is sufficient to infer that, after smoking 

cessation, the risk of stroke approaches that of never 

smokers. 

7. The evidence is suggestive but not sufficient to infer 

that smoking cessation reduces the risk of atrial 

fibrillation. 
Executive Summary 7

Smoking Cessation

8. The evidence is suggestive but not sufficient to infer 

that smoking cessation reduces the risk of sudden 

cardiac death among persons without coronary 

heart disease. 

9. The evidence is suggestive but not sufficient to infer 

that smoking cessation reduces the risk of heart 

failure among former smokers compared with persons who continue to smoke. 

10. Among patients with left-ventricular dysfunction, 

the evidence is suggestive but not sufficient to infer 

that smoking cessation leads to increased survival 

and reduced risk of hospitalization for heart failure. 

11. The evidence is suggestive but not sufficient to infer 

that smoking cessation reduces the risk of venous 

thromboembolism. 

12. The evidence is suggestive but not sufficient to 

infer that smoking cessation substantially reduces 

the risk of peripheral arterial disease among former 

smokers compared with persons who continue to 

smoke, and that this reduction appears to increase 

with time since cessation. 

13. The evidence is suggestive but not sufficient to infer 

that, among patients with peripheral arterial disease, smoking cessation improves exercise tolerance, reduces the risk of amputation after peripheral 

artery surgery, and increases overall survival.

14. The evidence is sufficient to infer that smoking cessation substantially reduces the risk of abdominal 

aortic aneurysm in former smokers compared with 

persons who continue to smoke, and that this reduction increases with time since cessation. 

15. The evidence is suggestive but not sufficient to infer 

that smoking cessation slows the expansion rate of 

abdominal aortic aneurysm.

Smoking Cessation After a Diagnosis of 

Coronary Heart Disease

1. In patients who are current smokers when diagnosed with coronary heart disease, the evidence 

is sufficient to infer a causal relationship between 

smoking cessation and a reduction in all-cause 

mortality.

2. In patients who are current smokers when diagnosed with coronary heart disease, the evidence 

is sufficient to infer a causal relationship between 

smoking cessation and reductions in deaths due to 

cardiac causes and sudden death. 

3. In patients who are current smokers when diagnosed with coronary heart disease, the evidence 

is sufficient to infer a causal relationship between 

smoking cessation and reduced risk of new and 

recurrent cardiac events.

Chronic Respiratory Disease

Chronic Obstructive Pulmonary Disease

1. Smoking cessation remains the only established 

intervention to reduce loss of lung function over time 

among persons with chronic obstructive pulmonary 

disease and to reduce the risk of developing chronic 

obstructive pulmonary disease in cigarette smokers.

2. The evidence is suggestive but not sufficient to infer 

that airway inflammation in cigarette smokers persists months to years after smoking cessation.

3. The evidence is suggestive but not sufficient to infer 

that changes in gene methylation and profiles of 

proteins occur after smoking cessation.

4. The evidence is inadequate to infer the presence or 

absence of a relationship between smoking cessation and changes in the lung microbiome.

Asthma

1. The evidence is suggestive but not sufficient to infer 

that smoking cessation reduces asthma symptoms 

and improves treatment outcomes and asthmaspecific quality-of-life scores among persons with 

asthma who smoke. 

2. The evidence is suggestive but not sufficient to infer 

that smoking cessation improves lung function 

among persons with asthma who smoke. 

Reproductive Health

1. The evidence is sufficient to infer that smoking cessation by pregnant women benefits their health and 

that of their fetuses and newborns.

2. The evidence is inadequate to infer that smoking 

cessation before or during early pregnancy reduces 

the risk of placental abruption compared with continued smoking. 

3. The evidence is inadequate to infer that smoking 

cessation before or during pregnancy reduces the 
A Report of the Surgeon General

8 Executive Summary

risk of placenta previa compared with continued 

smoking. 

4. The evidence is inadequate to infer that smoking 

cessation before or during pregnancy reduces the 

risk of premature rupture of the membranes compared with continued smoking. 

5. The evidence is inadequate to infer that smoking 

during early or mid-pregnancy alone, and not during 

late pregnancy, is associated with a reduced risk of 

preeclampsia.

6. The evidence is sufficient to infer that women who 

quit smoking before or during pregnancy gain more 

weight during gestation than those who continue to 

smoke. 

7. The evidence is suggestive but not sufficient to infer 

that women who quit smoking before or during 

pregnancy gain more weight during gestation than 

nonsmokers. 

8. The evidence is inadequate to infer that smoking 

cessation during pregnancy increases the risk of 

gestational diabetes. 

9. The evidence is sufficient to infer that smoking 

cessation during pregnancy reduces the effects of 

smoking on fetal growth and that quitting smoking 

early in pregnancy eliminates the adverse effects of 

smoking on fetal growth.

10. The evidence is inadequate to determine the gestational age before which smoking cessation should 

occur to eliminate the effects of smoking on fetal 

growth. 

11. The evidence is sufficient to infer that smoking cessation before or during early pregnancy reduces the 

risk for a small-for-gestational-age birth compared 

with continued smoking. 

12. The evidence is suggestive but not sufficient to infer 

that women who quit smoking before conception or 

during early pregnancy have a reduced risk of preterm delivery compared with women who continue 

to smoke. 

13. The evidence is suggestive but not sufficient to infer 

that the risk of preterm delivery in women who quit 

smoking before or during early pregnancy does not 

differ from that of nonsmokers. 

14. The evidence is inadequate to infer that smoking cessation during pregnancy reduces the risk of stillbirth. 

15. The evidence is inadequate to infer that smoking 

cessation during pregnancy reduces the risk of perinatal mortality among smokers. 

16. The evidence is inadequate to infer that women who 

quit smoking before or during early pregnancy have 

a reduced risk for infant mortality compared with 

continued smokers.

17. The evidence is inadequate to infer an association 

between smoking cessation, the timing of cessation, 

and female fertility or fecundity.

18. The evidence is suggestive but not sufficient to infer 

that smoking cessation reduces the risk of earlier age 

at menopause compared with continued smoking.

19. The evidence is inadequate to infer that smoking 

cessation reduces the effects of smoking on male 

fertility and sperm quality.

20. The evidence is suggestive but not sufficient to infer 

that former smokers are at increased risk of erectile 

dysfunction compared with never smokers. 

21. The evidence is inadequate to infer that smoking 

cessation reduces the risk of erectile dysfunction 

compared with continued smoking.

Chapter 5: The Benefits of Smoking 

Cessation on Overall Morbidity, 

Mortality, and Economic Costs

Chapter 5 considers broad indicators of burden in 

relation to smoking cessation, including morbidity, mortality, and economic costs. General measures of health can 

be informative because they provide an integrative indicator of the health burden placed on smokers and on society 

overall. Initially, the chapter considers how general indicators of health can change after smoking cessation. This 

type of information is critical to informing smokers about 

the potential benefits of cessation and serves as a strong 

rationale to provide interventions that can help increase 

the success of quitting smoking. Such programs may be 

offered through healthcare organizations, communities, 

states, and other organizations. Smoking is known to generate healthcare and other economic costs and to affect the 

economics of the households of smokers (USDHHS 2014). 
Executive Summary 9

Smoking Cessation

In addition to the direct human costs that smoking 

places on persons and society, one general measure 

with acknowledged implications for public health policy 

and practice is the economic cost of smoking. Previous 

Surgeon General’s reports on tobacco have periodically 

reviewed the economic costs of smoking, as tracked by 

CDC’s Smoking-Attributable Mortality, Morbidity, and 

Economic Costs (SAMMEC) model. This chapter expands 

on this work by focusing on the most recently available 

scientific literature on the economic benefits of smoking 

cessation, while also complementing the kinds of cost 

estimates previously provided by SAMMEC.

Conclusions

1. The evidence is sufficient to infer that smoking cessation improves well-being, including higher quality 

of life and improved health status.

2. The evidence is sufficient to infer that smoking cessation reduces mortality and increases the lifespan.

3. The evidence is sufficient to infer that smoking 

exacts a high cost for smokers, healthcare systems, 

and society. 

4. The evidence is sufficient to infer that smoking cessation interventions are cost-effective.

Chapter 6: Interventions for 

Smoking Cessation and Treatments 

for Nicotine Dependence

Chapter 6 reviews both evidence-based and emerging 

treatments for smoking cessation. A large body of evidence 

highlights the efficacy of multiple treatments that can double 

or triple the rate of success in quitting smoking (Fiore et al. 

2008; Prochaska and Benowitz 2016). Specifically, current 

evidence-based treatment approaches to smoking cessation 

include several behavioral treatments—such as individual, 

group, and telephone counseling—and seven pharmacotherapies approved by FDA. These treatments have been 

shown to be effective when delivered across a wide variety of 

settings, via several platforms, and to a diversity of populations—including groups that have been disproportionately 

impacted by tobacco use, such as low-income populations, 

and populations with other comorbid medical conditions, 

including behavioral health conditions (U.S. Preventive 

Services Task Force 2015). 

This chapter also highlights key topics and developments associated with the content and delivery of smoking 

cessation interventions, with a focus on emerging evidence 

that can inform future smoking cessation efforts. Promising 

directions include leveraging emerging technologies to 

enhance the sustained engagement of smokers in cessation 

treatment, accelerating the integration of cessation services across multiple platforms and within healthcare systems, and developing new tobacco cessation medications 

and new indications for existing cessation medications.

Conclusions

1. The evidence is sufficient to infer that behavioral 

counseling and cessation medication interventions 

increase smoking cessation compared with self-help 

materials or no treatment. 

2. The evidence is sufficient to infer that behavioral 

counseling and cessation medications are independently effective in increasing smoking cessation, 

and even more effective when used in combination. 

3. The evidence is sufficient to infer that proactive quitline counseling, when provided alone or in combination with cessation medications, increases smoking 

cessation. 

4. The evidence is sufficient to infer that short text 

message services about cessation are independently 

effective in increasing smoking cessation, particularly if they are interactive or tailored to individual 

text responses.

5. The evidence is sufficient to infer that web or Internetbased interventions increase smoking cessation and 

can be more effective when they contain behavior 

change techniques and interactive components.

6. The evidence is inadequate to infer that smartphone 

apps for smoking cessation are independently effective in increasing smoking cessation.

7. The evidence is sufficient to infer that combining 

short- and long-acting forms of nicotine replacement 

therapy increases smoking cessation compared with 

using single forms of nicotine replacement therapy. 

8. The evidence is suggestive but not sufficient to infer 

that pre-loading (e.g., initiating cessation medication in advance of a quit attempt), especially with 

the nicotine patch, can increase smoking cessation. 

9. The evidence is suggestive but not sufficient to infer 

that very-low-nicotine-content cigarettes can reduce 

smoking and nicotine dependence and increase 
A Report of the Surgeon General

10 Executive Summary

smoking cessation when full-nicotine cigarettes are 

readily available; the effects on cessation may be further strengthened in an environment in which conventional cigarettes and other combustible tobacco 

products are not readily available. 

10. The evidence is inadequate to infer that e-cigarettes, 

in general, increase smoking cessation. However, 

the evidence is suggestive but not sufficient to infer 

that the use of e-cigarettes containing nicotine is 

associated with increased smoking cessation compared with the use of e-cigarettes not containing 

nicotine, and the evidence is suggestive but not sufficient to infer that more frequent use of e-cigarettes 

is associated with increased smoking cessation compared with less frequent use of e-cigarettes. 

11. The evidence is sufficient to infer that certain life 

events—including hospitalization, surgery, and 

lung cancer screening—can trigger attempts to quit 

smoking, uptake of smoking cessation treatment, 

and smoking cessation. 

12. The evidence is suggestive but not sufficient to infer 

that fully and consistently integrating standardized, 

evidence-based smoking cessation interventions 

into lung cancer screening increases smoking cessation while avoiding potential adverse effects of this 

screening on cessation outcomes.

13. The evidence is suggestive but not sufficient to infer 

that cytisine increases smoking cessation.

Chapter 7: Clinical-, System-, and 

Population-Level Strategies that 

Promote Smoking Cessation

Chapter 7 focuses on broad strategies that can facilitate the integration of individual components of treatment 

for smoking cessation, as discussed in Chapter 6, into routine clinical care—making cessation interventions available and accessible to individual smokers and creating 

conditions whereby smokers become aware of these interventions and are motivated to use them. 

Clinical-, system-, and population-level strategies 

can broadly influence the behavior of smokers as they try to 

quit or think about quitting smoking. Actions taken at the 

clinical and health system levels typically target quitting 

behavior directly and generally focus on the use or effectiveness of treatments for smoking cessation. These actions 

include implementing policies that transform systems of 

care to better address tobacco use and dependence; promoting evidence-based treatments for tobacco cessation; 

and enacting policies that are clinically focused, address 

health insurance coverage, and promote cessation. In contrast, population-based strategies are aimed at influencing 

tobacco cessation at a macro level by motivating smokers 

to quit and by providing an environment that supports or 

simplifies efforts to quit or lowers barriers to quitting that 

smokers might encounter. Population-based strategies 

include increasing the price of and/or the tax on cigarettes 

and other tobacco products; restricting where tobacco can 

be used by implementing smokefree and tobacco-free policies; adequately funding tobacco control programs at the 

state level; carrying out mass media campaigns (CDC 2018; 

FDA 2018) making changes to the tobacco retail density and 

point-of-sale environments; and developing product regulations, including regulating nicotine content and requiring 

pictorial health warnings. Importantly, combining clinical 

and health system-based and macro-level strategies can 

have a synergistic effect on improving cessation outcomes.

This chapter does not attempt to provide a review 

of all tobacco control policy actions that may result in 

smokers attempting to quit or that may increase quit success outside the context of cessation treatment interventions; these have been covered comprehensively in previous 

Surgeon General’s reports, including the 50th anniversary 

report, The Health Consequences of Smoking—50 Years 

of Progress (USDHHS 2014), as well as in other documents 

(National Cancer Institute and World Health Organization 

2017; World Health Organization 2019).

Conclusions

1. The evidence is sufficient to infer that the development and dissemination of evidence-based clinical 

practice guidelines increase the delivery of clinical 

interventions for smoking cessation. 

2. The evidence is sufficient to infer that with adequate 

promotion, comprehensive, barrier-free, evidencebased cessation insurance coverage increases the 

availability and utilization of treatment services for 

smoking cessation.

3. The evidence is sufficient to infer that strategies that 

link smoking cessation-related quality measures 

with payments to clinicians, clinics, or health systems increase the rate of delivery of clinical treatments for smoking cessation.

4. The evidence is sufficient to infer that tobacco quitlines are an effective population-based approach 

to motivate quit attempts and increase smoking 

cessation. 
Executive Summary 11

Smoking Cessation

5. The evidence is suggestive but not sufficient to infer 

that electronic health record technology increases 

the rate of delivery of smoking cessation treatments.

6. The evidence is sufficient to infer that increasing 

the price of cigarettes reduces smoking prevalence, reduces cigarette consumption, and increases 

smoking cessation.

7. The evidence is sufficient to infer that smokefree 

policies reduce smoking prevalence, reduce cigarette 

consumption, and increase smoking cessation.

8. The evidence is sufficient to infer that mass media 

campaigns increase the number of calls to quitlines 

and increase smoking cessation.

9. The evidence is sufficient to infer that comprehensive 

state tobacco control programs reduce smoking prevalence, increase quit attempts, and increase smoking 

cessation. 

10. The evidence is sufficient to infer that large, pictorial 

health warnings increase smokers’ knowledge about 

the health harms of smoking, interest in quitting, 

and quit attempts and decrease smoking prevalence.

11. The evidence is suggestive but not sufficient to infer 

that plain packaging increases smoking cessation.

12. The evidence is suggestive but not sufficient to infer 

that decreasing the retail availability of tobacco 

products and exposure to point-of-sale tobacco marketing and advertising increases smoking cessation. 

13. The evidence is suggestive but not sufficient to infer 

that restricting the sale of certain types of tobacco 

products, such as menthol and other flavored products, increases smoking cessation, especially among 

certain populations. 

Chapter 8: A Vision for the Future

Chapter 8 discusses the past, present, and future 

of tobacco cessation in the United States. Specifically, 

it provides a historical perspective, discusses the current tobacco control landscape, and provides a vision for 

enhancing tobacco cessation in the United States. 

Although substantial progress has been made to 

reduce smoking in the United States over the past five 

decades, by increasing adult smoking cessation and by 

reducing youth smoking initiation, more can and should 

be done. The following major conclusions from this report 

provide evidence that points to an urgent need for intensified and coordinated actions to reduce the considerable—and preventable—human and financial burden of 

smoking in the United States:

• More than three out of five U.S. adults who have ever 

smoked cigarettes have quit. Although a majority of 

cigarette smokers make a quit attempt each year, 

less than one-third use FDA-approved cessation 

medications or behavioral counseling to support 

these attempts. 

• Smoking places a substantial financial burden 

on smokers, their families, and healthcare systems. Smoking cessation reduces the burden on 

smokers and their families and can reduce smokingattributable healthcare expenditures. 

Considerable disparities exist in the prevalence of 

smoking across the U.S. population; such prevalence is 

higher in some subgroups. Similarly, the prevalence of key 

indicators of smoking cessation— making quit attempts, 

receiving advice to quit from a health professional, and 

using cessation therapies—also varies across the population, with lower prevalence among some subgroups. 

To increase smoking cessation and reduce smoking in the 

United States, this report outlines a broad range of welldefined and effective population-based interventions that 

are necessary, at present, to help the 34 million American 

adults who currently smoke cigarettes quit:

• Fully funded, comprehensive statewide tobacco control programs; 

• Higher average retail prices of cigarettes—at least 

$10 a pack; 

• Complete protection of the entire U.S. population 

from exposure to secondhand smoke through comprehensive indoor smokefree policies in workplaces, 

restaurants, and bars; 

• High-impact media campaigns, such as CDC’s Tips 

From Former Smokers, that run with sufficient reach, 

frequency, and duration—ideally for 12  months a 

year; and 

• Product regulations, such as requiring pictorial 

health warnings.

However, these population-based actions and the 

more aggressive use of the evidence-based policies and 
A Report of the Surgeon General

12 Executive Summary

programs reviewed in Chapter 7 are not enough. An array 

of effective clinical and health system-based interventions should also be implemented to increase smoking 

cessation and treat tobacco use and dependence in the 

United States: 

• Increasing the appeal and reach of existing evidencebased interventions to individuals, including leveraging emerging technologies and accelerating the 

integration of cessation services across multiple 

platforms and in healthcare systems;

• Increasing the effectiveness of existing interventions, including recommending the combination of 

short- and long-acting forms of NRT, combined with 

behavioral support interventions, as first-line treatment for tobacco use;

• Conducting research to develop and better understand cessation interventions that have the potential 

for greater reach and/or effectiveness than existing 

interventions or that appeal to and are used by different populations of smokers; 

• Conducting research to develop and better understand cessation interventions that are safe and effective among both youth and adults, including those 

that address the diversity of tobacco products being 

used by these populations, including e-cigarettes; 

• Embedding policies and protocols for tobacco use 

screening and intervention into the clinical workflow; embedding prompts, decision support, and 

documentation tools into health records, such as 

electronic health records; and distributing specific 

components of the intervention across the broader 

healthcare team to reduce the burden on timeconstrained physicians and to reinforce the importance of cessation to patients; 

• Adopting policies to make the provision of cessation care in health systems more routine, as well as 

policies that remove cost and barriers to access for 

patients to increase the delivery and utilization of 

tobacco dependence treatment; 

• Providing timely and relevant clinical guidelines 

and clinical quality measures to ensure that clinicians and health systems intervene consistently 

with tobacco users; 

• Providing barrier-free cessation insurance coverage—without prior authorization, duration limits, 

cost-sharing, or other barriers that impede smokers’ 

access to cessation treatments—to increase the 

availability and utilization of treatment services for 

smoking cessation; 

• Ensuring comprehensive cessation insurance benefits for all smokers that include coverage of all 

evidence-based cessation interventions, including 

brief and intensive counseling and all FDA-approved 

medications, including combination NRT therapy; 

• Promoting cessation coverage and services, whether 

offered through a health insurer or an employee 

wellness program, to smokers and healthcare providers to increase awareness and use of the covered 

treatments; coverage alone, without promotion, is 

not sufficient; and

• Adequately funding and promoting tobacco quitlines 

to enable their operations and services to function at 

levels sufficient to maximize their reach and impact. 

The implementation of scientifically proven interventions has been a hallmark of the successes made in 

combating the tobacco use epidemic in the United States 

for more than 50 years. However, the tobacco control community must remain nimble and vigilant in conducting 

and disseminating timely, high-quality scientific studies 

on best practices; in modernizing existing interventions 

to keep pace with the rapidly diversifying landscape of 

tobacco products; and in identifying emerging strategies to 

ensure more rapid elimination of the health and economic 

burden of tobacco use in the United States. To that end, 

several end-game strategies could help to increase cessation and reduce the disease and premature death caused by 

tobacco use. Strategies that have been proposed include:

• Implementing a tobacco product standard to lower 

the level of nicotine in cigarettes to minimally addictive or nonaddictive levels, and

• Restricting the sale of tobacco products, such as 

prohibitions on entire categories of flavored tobacco 

products, including menthol.

Such actions have the potential to accelerate 

increases in smoking cessation and declines in the prevalence of smoking in the United States, thus hastening the 

end of the tobacco epidemic. However, these actions and the 

extensive body of evidence-based clinical, health system, 

and population-based tobacco prevention, control, and cessation strategies that are outlined in this report are a necessary but insufficient means to end the tobacco epidemic. 
Executive Summary 13

Smoking Cessation

To achieve success, we must work together to maximize 

resources and coordinate efforts across a wide range of 

stakeholders. Stakeholders who have a role to play include 

federal, state, local, tribal, and territorial governments; 

voluntary health agencies; nongovernmental and community-based organizations; civic and community leaders; 

public health and healthcare professionals; researchers; 

and individuals (USDHHS 2016). Stakeholders must also 

continue to hold the tobacco industry accountable for its 

role in creating, obscuring, and perpetuating the tobacco 

use epidemic in the United States (USDHHS 2014). 

Action at the federal level is a key lever to success, 

but such action must be complemented by subnational 

and nongovernmental efforts to continue to denormalize 

tobacco use and advance the strategies that we know work 

to combat the devastating effects of tobacco use on society 

(USDHHS 2014). Each stakeholder can make unique and 

critical contributions toward reducing tobacco-related disease and death in the United States. In particular, there are 

opportunities for practitioners, experts, and researchers 

who have traditionally focused primarily on populationbased tobacco control policy interventions, to collaborate 

more closely with their counterparts who have traditionally focused on cessation interventions as part of a broader 

effort to build linkages.

We are at the precipice of a critical period in the 

more-than-half-century history of the tobacco control 

movement in the United States. The considerable reduction in the prevalence of smoking since the mid-1960s is 

an important public health achievement, which has been 

driven in part by increases in adult smoking cessation 

and the multiple advances in smoking cessation interventions since the last Surgeon General’s report on this topic 

nearly three decades ago (USDHHS 1990). However, we 

cannot rest on our laurels. More work must be done, and 

we have the experience and wherewithal to do it. Equipped 

with both science and resolve, we will continue to move 

forward to end the tobacco epidemic in the United States. 

Working together, we can make tobacco-related disease 

and death a thing of the past.
A Report of the Surgeon General

14 Executive Summary

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