1

Chapter 1

Introduction, Conclusions, and the Evolving Landscape 

of Smoking Cessation

Introduction 3

Organization of the Report 4

Preparation of the Report 5

Scientific Basis of the Report 5

Major Conclusions 6

Chapter Conclusions 7

Chapter 2: Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 7

Chapter 3: New Biological Insights into Smoking Cessation 7

Chapter 4: The Health Benefits of Smoking Cessation 8

Cancer 8

Smoking Cessation After a Cancer Diagnosis 8

Cardiovascular Disease 8

Smoking Cessation After a Diagnosis of Coronary Heart Disease 9

Chronic Respiratory Disease 9

Reproductive Health 9

Chapter 5: The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs 10

Chapter 6: Interventions for Smoking Cessation and Treatments for Nicotine Dependence 10

Chapter 7: Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 11

The Evolving Landscape of Smoking Cessation 12

Historical Context of Smoking Cessation 12

Addiction Versus Habit 12

Coverage of Smoking Cessation, Nicotine, and Addiction in Surgeon General’s Reports 13

Coverage of Smoking Cessation 13

Coverage of Nicotine and Addiction 14

Perspectives on Smoking Cessation 15

Development and Evolution of a Paradigm for Treating Nicotine Addiction 15

Epidemiologic Shifts in Smoking Cessation 16

Changes in the Patterns of Smoking and Population Characteristics of Smokers 16

Changes in the Products Used by Smokers 16

Developments in Approaches to Smoking Cessation at the Individual Level 17

Pharmacotherapy 17

Behavioral Interventions 17

Treating Tobacco Use and Dependence 18

Evolution of Approaches to Smoking Cessation at the Population Level 19

More Intensity Versus Higher Reach of Support Services 19

Population-Based Interventions 20
2

Quitlines 20

Mass Media Campaigns 20

Healthcare Systems 21

Health Insurance Coverage 22

E-Cigarettes: Potential Impact on Smoking Cessation 23

Implications of E-Cigarette Characteristics for Smoking Cessation 23

Summary 24

References 26
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 3

Smoking Cessation

Introduction

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 [NIDA] 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 about 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 strategies 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 1.1). 

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 electronic cigarettes 

(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 both 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 evidence-based clinical-, health system-, 

and population-based tobacco prevention, control, and 
A Report of the Surgeon General

4 Chapter 1

cessation strategies that are outlined in this report are a 

necessary but insufficient means to 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 1.1 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.

Organization of the Report

This chapter summarizes the report, identifies its 

major conclusions, and presents the conclusions from each 

chapter. It also offers an overview of the evolving landscape 

of smoking cessation and key developments since the 1990 

Surgeon General’s report. Chapter 2 (“Patterns of Smoking 

Cessation Among U.S. Adults, Young Adults, and Youth”) 

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. Chapter  3 (“New Biological Insights into Smoking 

Cessation”) reviews several areas of intensive research 

since the 2010 Surgeon General’s report on how tobacco 

smoke causes disease: cellular and molecular biology of 

nicotine addiction; vaccines and other immunotherapies as 

treatments for tobacco addiction; neurobiological insights 

into smoking cessation obtained from noninvasive neuroimaging; and genetics of smoking behaviors and cessation. 

Chapter  4 (“The Health Benefits of Smoking Cessation”) 

reviews the more recent findings on disease risks from 

smoking and benefits after smoking cessation for major 

types of chronic diseases, including cardiovascular and 

respiratory systems, cancer, and a wide range of reproductive outcomes. Chapter  5 (“The Benefits of Smoking 

Cessation on Overall Morbidity, Mortality, and Economic 

Costs”) discusses general indicators of health that change 

after smoking cessation, the health benefits of smoking cessation on all-cause mortality, and the economic benefits of 

smoking cessation. Chapter 6 (“Interventions for Smoking 

Cessation and Treatments for Nicotine Dependence”) 

reviews the evidence on current and emerging treatments 

for smoking cessation, including research that has been 

conducted since the 2008 U.S. Public Health Service’s 
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 5

Smoking Cessation

Clinical Practice Guideline, Treating Tobacco Use and 

Dependence: 2008 Update (Fiore et al. 2008). Chapter  7 

(“Clinical-, System-, and Population-Level Strategies 

that Promote Smoking Cessation”) focuses on clinical-, 

system-, and population-level strategies that combine individual components of treatment for smoking cessation with 

routine clinical care, making cessation interventions available and accessible to individual smokers and creating conditions whereby smokers are informed of these interventions and are motivated to use them. Chapter 8 (“A Vision 

for the Future”) outlines broad strategies to accelerate the 

progress that has been made in helping smokers quit.

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 focuses primarily 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 a 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 

was analyzed to identify causal associations according 

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, 
A Report of the Surgeon General

6 Chapter 1

• 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 about 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.

Major Conclusions

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.
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 7

Smoking Cessation

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 

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.

Chapter Conclusions

Chapter 2: Patterns of Smoking 

Cessation Among U.S. Adults, 

Young Adults, and Youth

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

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.
A Report of the Surgeon General

8 Chapter 1

Chapter 4: The Health Benefits of 

Smoking Cessation

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.

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.
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 9

Smoking Cessation

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 

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.
A Report of the Surgeon General

10 Chapter 1

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

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

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 
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 11

Smoking Cessation

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 

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

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.

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.
A Report of the Surgeon General

12 Chapter 1

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.

The Evolving Landscape of Smoking Cessation

This section of the chapter reviews the history of 

smoking cessation, from its early origins to the modern 

era, including the changes that have occurred since publication of the 1990 Surgeon General’s report. It also highlights developments that have shaped current initiatives in 

smoking cessation and will set the stage for the chapters 

that follow. Finally, this section highlights a broad set of 

interventions that have been implemented over the past 

three decades and are proven to be effective at helping 

people quit successfully. These interventions, which are 

now being integrated into clinical care and societal policies, 

include (a) low-intensity interventions, such as telephone 

quitlines; (b) brief but systematically repeated interventions in primary care settings; (c) over-the-counter medications; and (d) public policy approaches, such as increases 

in tobacco prices (e.g., through taxation), comprehensive 

policies to make indoor environments smokefree, and mass 

media campaigns that increase motivation to quit and may 

help sustain quit attempts (CDC 2014a; USDHHS 2014).

Historical Context of Smoking 

Cessation

Addiction Versus Habit

In 2017, a federal court ordered the major U.S. tobacco 

companies to run television and newspaper ads that tell the 

American public the truth about the dangers of smoking 

and secondhand smoke (U.S. Department of Justice 2017b). 

The ads included several statements related to the addictiveness of nicotine:

• “Smoking is highly addictive. Nicotine is the addictive drug in tobacco”;

• “Cigarette companies intentionally designed cigarettes 

with enough nicotine to create and sustain addiction”;

• “It’s not easy to quit”; and 

• “When you smoke, the nicotine actually changes the 

brain—that’s why quitting is so hard” (U.S. Department 

of Justice 2017a; Farber et al. 2018, p. 128).

However, previously secret documents from the 

tobacco industry reveal that the tobacco industry was 

aware of the addictive nature of nicotine for decades, 

long before they publicly acknowledged it or were eventually ordered by the court to publicly acknowledge it 

(Elias et al. 2018). In fact, the tobacco industry had been 

engineering cigarettes for decades to improve the rapid 

delivery of nicotine (Proctor 2011). For years, the tobacco 

industry coordinated well-financed, systematic efforts to 

deny the addictiveness of nicotine and the need for users 

to quit smoking, thereby trivializing the harms of tobacco 

use while promoting the benefits of nicotine (Hirschhorn 

2009; USDHHS 2014). The industry did this using welldocumented tactics, including aggressive funding and 

support for academic, medical, and community organizations that were sympathetic to this perspective 

(Proctor 2011).

Addiction to any substance often brings on a variety 

of efforts to overcome or treat it. However, until the late 

twentieth century, clinical and public health approaches 

to smoking cessation often treated smoking as a habit 

rather than as an addiction (USDHEW 1964). The tobacco 

industry has asserted for many years in public messaging 

and litigation that smoking is a personal choice (Friedman 

et  al. 2015). Indeed, both smoking and smoking cessation were considered personal choices; the idea was that 
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 13

Smoking Cessation

if persons started smoking cigarettes, they could quit if 

they truly wanted to, putting the onus on the individual 

smoker to quit using his or her own motivation and desire 

to do so. The Surgeon General first concluded in 1988 that 

”cigarettes and other forms of tobacco are addicting,” and 

“nicotine is the drug in tobacco that causes addiction” 

(USDHHS 1988, p. 9). Eventually, intensive medical treatments and protocols—such as the use of multiple medications for long periods of time, long-term psychological 

counseling, and inpatient hospitalization—were developed to address the highly addictive nature of nicotine 

(Fiore et al. 2008). However, between 2000 and 2015, less 

than one-third of U.S. adult cigarette smokers reported 

using evidence-based cessation treatments, such as behavioral counseling and/or medication, when trying to quit 

smoking (Babb et al. 2017).

The first comprehensive clinical practice guideline for smoking cessation was produced by the federal 

government in 1996 and emphasized the role of healthcare providers in providing assessment and treatment 

interventions for smoking with patients who smoke 

(Fiore et al. 1996). In 2008, an updated federal guideline, Treating Tobacco Use and Dependence: 2008 Update

(hereafter referred to as the Clinical Practice Guideline), 

was published (Fiore et al. 2008). This guideline uses language similar to that used in helping persons quit other 

addictive substances and is discussed in more detail in 

Chapter 7.

With the shift toward an improved understanding 

of the nature of nicotine addiction, terminology used 

to describe tobacco use has also shifted. The Diagnostic 

and Statistical Manual of Mental Disorders (5th edition) 

is the primary clinical source of diagnostic criteria for 

mental health disorders. It provides diagnostic criteria for 

“tobacco use disorder,” which includes physiologic dependence, impaired control, and social impairment, among 

others (American Psychiatric Association 2013). These 

diagnostic criteria align with those for other substance use 

disorders and acknowledge the physical, psychological, 

and environmental components of addiction. However, as 

noted in the Clinical Practice Guideline, although not all 

tobacco use results in tobacco use disorder, any tobacco 

use has risks and, therefore, warrants intervention (Fiore 

et al. 2008). Accordingly, throughout this report, the term 

“tobacco use and dependence” is used to be inclusive of 

all patterns of use and to acknowledge the multifactorial 

and chronic relapsing nature of nicotine addiction. The 

term “nicotine dependence” is used specifically to refer 

to physiologic dependence on nicotine. This terminology 

aligns with that used in the Clinical Practice Guideline, 

which further details why the term “tobacco use and 

dependence” is most appropriate when discussing cessation interventions (Fiore et al. 2008).

Coverage of Smoking Cessation, 

Nicotine, and Addiction in Surgeon 

General’s Reports

Coverage of cessation, nicotine, and addiction in 

Surgeon General’s reports has evolved greatly since 1964, 

reflecting the evolution of scientific understanding of 

addiction to nicotine and its treatment.

Coverage of Smoking Cessation

Of the 34 Surgeon General’s reports on smoking 

and health published to date, this is the second to address 

smoking cessation as the main topic. Even so, beginning 

with the first report in 1964, evidence reviewed in various 

reports has supported some conclusions related to the 

health benefits of smoking cessation. Over time, as the 

epidemiologic findings from prospective cohort studies 

became more abundant and covered longer periods of 

time since quitting smoking, conclusions began to mount 

on the decline in risks for major smoking-caused diseases 

after cessation. In fact, declines in risk after cessation figured into the causal inference process presented in the 

reports, which documented a decrease in health risks after 

withdrawal of smoking—the presumptive causal agent.

The 1964 Surgeon General’s report reviewed findings from seven prospective cohort studies that had 

included sufficient numbers of former smokers to provide 

estimates about cause-specific relative risk for mortality 

from selected diseases (USDHEW 1964). The data from the 

cohort studies were complemented by case-control studies 

for some cancer sites that had also addressed a change in 

risk after smoking cessation. For all-cause mortality, the 

1964 report stated that compared with never smokers, relative mortality was 40% higher among former smokers 

and 70% higher among current smokers. For lung cancer, 

quantitative relationships with smoking patterns were 

described as follows: “The risk of developing lung cancer 

increases with duration of smoking and the number of 

cigarettes smoked per day, and is diminished by discontinuing smoking” (p. 37). In considering the causal nature 

of the association between smoking and lung cancer, the 

report stated, “Where discontinuance, time since discontinuance, and amount smoked prior to discontinuance 

were considered in either retrospective studies or, with 

more detail, in prospective studies, these all showed lower 

risks for ex-smokers, still lower risks as the length of time 

since discontinuance increased, and lower risks among 

ex-smokers if they had been light smokers” (p. 188). The 

report did not conclude that smoking caused cardiovascular disease, but it noted a lower risk of death from cardiovascular disease among former smokers compared with 

continuing smokers and stated, “Although the causative 
A Report of the Surgeon General

14 Chapter 1

role of cigarette smoking in deaths from coronary disease 

is not proven, the Committee considers it more prudent 

from the public health viewpoint to assume that the established association has causative meaning than to suspend 

judgment until no uncertainty remains” (p. 32).

In ensuing Surgeon General’s reports through the 

1970s, the health benefits of smoking cessation did not 

receive systematic attention, but the results identified 

a declining risk for some diseases after cessation. The 

1979 report offered detailed reviews for major diseases, 

and it concluded that compared with smokers, risks were 

lower among former smokers for all-cause mortality, 

atherosclerosis and coronary heart disease, lung cancer, 

larynx cancer, lung function, and respiratory symptoms (USDHEW 1979). Three Surgeon General’s reports 

released in the early 1980s focused on the health consequences of smoking on specific major disease categories: 

cancer (USDHHS 1982), cardiovascular disease (USDHHS 

1983), and chronic lung disease (USDHHS 1984). Each 

report also examined the impact of smoking cessation 

on each of those disease categories. In 1988, the report 

reviewed the evidence to date on nicotine and drew major 

conclusions that nicotine was addictive (USDHHS 1988).

By 1990, the scope and depth of evidence on smoking 

cessation was sufficiently abundant to justify a full report, 

The Health Benefits of Smoking Cessation. The report’s 

conclusions expanded on those of earlier reports, summarizing descriptions of the temporal course of declining 

risk for many of the diseases caused by smoking (USDHHS 

1990). For example, the report concluded, “The excess risk 

of [coronary heart disease] caused by smoking is reduced 

by about half after 1 year of smoking abstinence and then 

declines gradually. After 15 years of abstinence, the risk of 

[coronary heart disease] is similar to that of persons who 

have never smoked” (p. 11).

Importantly, the 1990 report was the first to address 

smoking cessation and reproduction. That report offered 

strong conclusions with clinical implications related to 

reproduction and offered conclusions about the timing 

of cessation across gestation and implications for birthweight (USDHHS 1990).

The 2004 Surgeon General’s report, The Health 

Consequences of Smoking, covered active smoking and 

disease; and the 2014 Surgeon General’s report, The Health 

Consequences of Smoking—Fifty Years of Progress, again 

covered the full range of health consequences of smoking, 

providing conclusions that drew on data from long-running 

cohort studies that described how risks change in former 

smokers up to several decades after quitting. For example, 

the 2004 report concluded, “Even after many years of not 

smoking, the risk of lung cancer in former smokers remains 

higher than in persons who have never smoked” (USDHHS 

2004, p. 25). In contrast, regarding the effect of smoking in 

accelerating the decline of lung function, the report determined “[t]he evidence is sufficient to infer a causal relationship between sustained cessation from smoking and a 

return of the rate of decline in pulmonary function to that 

of persons who had never smoked” (p. 27). The 2014 report 

updated estimates of relative risks in former smokers, 

drawing on more contemporary cohorts, and used the estimates to calculate attributable mortality (USDHHS 2014). 

The extended follow-up of the cohort studies documented 

the benefits of cessation by early middle age for reducing 

the risk of death from any cause.

Coverage of Nicotine and Addiction

The 1964 Surgeon General’s report suggested that 

smoking was a form of habituation, stating that “[e]ven 

the most energetic and emotional campaigner against 

smoking and nicotine could find little support for the view 

that all those who use tobacco, coffee, tea, and cocoa are 

in need of mental care even though it may at some time in 

the future be shown that smokers and nonsmokers have 

different psychologic characteristics” (USDHEW 1964, 

pp. 351–352). The report used such words as “compulsion” 

and “habit” but did not consider nicotine to be addicting: 

“Proof of physical dependence requires demonstration of a 

characteristic and reproducible abstinence syndrome upon 

withdrawal of a drug or chemical which occurs spontaneously, inevitably, and is not under control of the subject. 

Neither nicotine nor tobacco comply with any of these 

requirements” (USDHEW 1964, p. 352). Correspondingly, 

the report emphasized habituation and not addiction: “The 

habitual use of tobacco is related primarily to psychological and social drives, reinforced and perpetuated by the 

pharmacologic actions of nicotine on the central nervous 

system” (USDHEW 1964, p. 354). In 1977, the National 

Institute on Drug Abuse began to support studies of cigarette smoking as a “dependence process,” comparing it 

to other drug addictions (Parascandola 2011). The monograph, The Behavioral Aspects of Smoking (Krasnegor 

1979), reflected an advancing understanding of the power 

of nicotine as a pharmacologic agent: “Nicotine has been 

proposed as the primary incentive in smoking [Jarvik 1973, 

as cited in Krasnegor 1979] and may be instrumental in 

the establishment of the smoking habit. Whether or not 

it is the only reinforcing agent, it is still the most powerful pharmacological agent in cigarette smoke” (p. 12). 

The 1979 Surgeon General’s report, Smoking and Health, 

devoted considerable attention to the behavioral aspects 

of smoking, but it still did not use the term “addiction” 

(USDHEW 1979). That report also concluded that there was 

general acceptance of the existence of a tobacco withdrawal 

syndrome, which was more prominent in heavy smokers.

The 1988 Surgeon General’s report explored the 

clinical and public health implications of smoking, with 
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 15

Smoking Cessation

several major conclusions serving as an indictment of the 

addictiveness of nicotine in cigarettes. In fact, this report 

stated for the first time that cigarettes are addictive and 

function in a similar fashion to cocaine and heroin use. 

The three major conclusions of that report were:

• “Cigarettes and other forms of tobacco are addicting”;

• “Nicotine is the drug in tobacco that causes addiction”; and 

• “The pharmacologic and behavioral processes that 

determine tobacco addiction are similar to those 

that determine addiction to drugs such as heroin 

and cocaine” (USDHHS 1988, p. 9).

Later Surgeon General’s reports on tobacco have 

addressed the subsequent scientific advances in the 

area of smoking and addiction, particularly the 2010 

report on mechanisms by which smoking causes disease 

(USDHHS 2010).

Perspectives on Smoking Cessation

In 2015, most smokers stated that they wanted to 

quit smoking (68%), and about 56% of smokers made 

a serious attempt to quit; however, only about 7% of 

smokers reported that they had recently quit (Babb 

et  al. 2017). Despite evidence demonstrating that using 

smoking cessation pharmacotherapy with behavioral support is more effective than quitting without these treatments, most smokers who had recently quit reported 

that they did not quit with medication or counseling 

assistance (see Chapter 6). Proponents of encouraging 

smokers to quit without treatment, often called quitting 

“cold turkey,” point to data indicating that most smokers 

who quit successfully do so without medications or any 

type of formal assistance, as well as to population surveys 

suggesting that cold-turkey quitters do as well or better 

than those who use over-the-counter NRTs. Proponents of 

this approach also suggest that medicalization may disempower smokers and create artificial barriers to quitting 

(Alpert et al. 2013; Polito 2013). In contrast, others note 

that because of a lack of insurance coverage and other barriers, many smokers have little choice but to quit without 

formal treatment. Selection bias may also play a factor, as 

the most heavily addicted smokers are those most likely to 

use NRT, but these smokers also have a lower likelihood of 

success. In addition, most of those who use NRT do so for 

short periods of time or at lower-than-recommended doses 

and do not have adjunctive support available from tobacco 

cessation quitlines or other interventions (Amodei and 

Lamb 2008). There are also issues of recall and attribution 

bias, which may make smokers more likely to report their 

most proximal experiences with use or nonuse of pharmacologic smoking cessation aids and/or behavioral supports 

and not to report previous quit attempts during which 

they used pharmacologic aids and/or behavioral support.

During most of the twentieth century, smokers 

who wanted to quit had limited resources to do so, especially smokers with mental health or substance use disorders. For example, the investment in research required 

for behavioral, pharmacologic, and systems-level interventions that increase successful cessation had been relatively limited given the magnitude of tobacco-related 

disease burden and the size of the population affected 

(Dennis 2004; Carter et al. 2015; Hall et al. 2016). Even 

when interventions developed in the 1980s and 1990s 

were clearly shown to be effective, most health insurers 

and health systems showed little interest in providing 

coverage for or integrating into regular practice any new 

pharmacologic, behavioral, or systems approaches to cessation (see Chapter 6). Additionally, many medical schools 

provide only a small amount of time, if any, in their academic curriculum or programs for developing clinical 

skills to train future physicians in addressing tobacco use 

and dependence in patients (Ferry et al. 1999; Montalto 

et al. 2004; Powers et al. 2004; Association of American 

Medical Colleges 2007; Geller et al. 2008; Richmond et al. 

2009; Torabi et al. 2011; Griffith et al. 2013).

Development and Evolution of 

a Paradigm for Treating Nicotine 

Addiction

Clinicians’ views on smoking cessation shifted toward 

the end of the twentieth century. Given the increasing 

amount of evidence and awareness of the robust and widespanning beneficial effects of smoking cessation on various chronic diseases (USDHHS 1990), clinicians began to 

understand that promoting smoking cessation was among 

the most powerful interventions for increasing health, 

while merely advising patients to quit was insufficient in 

promoting smokers to initiate quitting and sustain abstinence without relapsing. Concurrently, researchers began 

to better understand the powerfully addictive properties 

of nicotine and the complexities of the nicotine addiction 

process (USDHHS 1988). This knowledge was disseminated widely to health professionals and the community 

(Fiore et al. 1996).

Nicotine addiction is now increasingly emphasized as a main driver of both the initiation and continuation of smoking. Thus, the medical community sees 
A Report of the Surgeon General

16 Chapter 1

the morbidity and mortality associated with smoking as 

clinical endpoints and nicotine addiction as the cause. 

Correspondingly, a growing number of intensive behavioral and pharmacologic treatments have become available to promote sustained abstinence.

Epidemiologic Shifts in Smoking 

Cessation

Chapter 2 provides a detailed discussion of key patterns and trends in cigarette smoking cessation in the 

United States. It 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.

Changes in the Patterns of Smoking and 

Population Characteristics of Smokers

The typical profile of the smoker has evolved over 

the years. The “hardening hypothesis” suggests that adults 

who continue to smoke cigarettes in the face of strengthening tobacco control policies and the increasing availability of efficacious cessation interventions will tend to be 

heavier smokers who are more highly addicted, less interested in quitting, and likely to have more difficulty in quitting (National Cancer Institute [NCI] 2003). Only a limited amount of evidence supports this hypothesis (Hughes 

2011). Instead of increases over time in the proportion of 

smokers with frequent or heavy patterns of smoking, as 

would be predicted by hardening, the proportion has actually decreased (Jamal et al. 2016). Furthermore, from 2005 

to 2015, the percentage of current smokers who were daily 

smokers declined from 80.8% to 75.7%, and the proportion of current smokers who smoked on only some days 

(i.e., nondaily smokers) increased from 19.2% to 24.3% 

(Jamal et al. 2016). Similarly, among daily smokers, the 

average number of cigarettes smoked per day declined 

from 16.7 in 2005 to 13.8 in 2014. However, when considering other measures of dependence, some modest and 

preliminary support exists for hardening among treatment-seeking smokers. For example, in a summary review 

by Hughes and colleagues (2011), two of four studies 

showed increases in dependence and decreases in quit 

rates, but similar trends were not found among the general population of smokers who had quit.

Reductions in the frequency and heaviness of 

smoking do not necessarily suggest that a simple continuation of current approaches to increase smoking cessation 

will increase or even maintain progress in successful quitting. Nondaily or light smokers would be expected to be 

less addicted to nicotine and, therefore, when motivated 

to make a cessation attempt, would find it easier to 

quit than heavier smokers. Still, helping light and nondaily smokers to quit presents challenges. For example, 

some light and nondaily smokers do not self-identify as 

smokers, do not believe that they are addicted to nicotine, 

do not feel that they are at risk of smoking-related health 

effects, and do not expect quitting to be difficult (Berg 

et al. 2013; Scott et al. 2015; Chaiton et al. 2016). The 2008 

Clinical Practice Guideline does not recommend cessation medications for use by light smokers, based on insufficient evidence of effectiveness in this population (Fiore 

et al. 2008). Ten years later, this gap in knowledge about 

treating light smokers is largely unchanged (Ebbert et al. 

2016) (see Chapter 6) and presents a barrier for addressing 

this growing subpopulation of smokers.

The prevalence of smoking is increasingly concentrated in the United States in populations that may face 

barriers to quitting. These include persons with behavioral health conditions (including mental health conditions or substance use disorders); persons of low socioeconomic status; persons who are lesbian, gay, bisexual, 

or transgender; American Indians/Alaska Natives; recent 

immigrants from countries with a high prevalence of 

smoking; residents of the South and Midwest; and persons with a disability. Such populations have a markedly 

higher prevalence of cigarette smoking than their respective counterparts, and the decline in the prevalence of 

smoking in the United States as a whole has been slower 

among these groups, particularly those with behavioral 

health conditions and those of lower socioeconomic 

status (Grant et al. 2004; Schroeder and Morris 2010; CDC 

2013b, 2016; Cook et  al. 2014; Szatkowski and McNeill 

2015) (see Chapter 2).

Changes in the Products Used by Smokers

The emergence of a wide array of new tobacco products and the increasing use of those products, combined 

with continued use of other conventional tobacco products, such as menthol cigarettes and smokeless tobacco, 

could complicate cessation efforts aimed at cigarette 

smoking (Trinidad et  al. 2010; USDHHS 2014; Villanti 

et al. 2016; Wang et al. 2016). These products include hookahs (water pipes), little cigars and cigarillos, e-cigarettes, 

and heated tobacco products. Cigarette smokers who also 

use one or more other tobacco products, generally known 

as “dual” or “poly” use, have higher dependence on nicotine and greater difficulty quitting (Wetter et  al. 2002; 

Bombard et al. 2007; Soule et al. 2015).

As of July  26, 2019, 11  states and the District of 

Columbia have passed laws legalizing nonmedical marijuana use (National Conference of State Legislatures 

[NCSL] 2019). Although not a tobacco product, marijuana is frequently used in combination with conventional 
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 17

Smoking Cessation

cigarettes or other tobacco products (e.g., cigars, 

e-cigarettes). For example, approximately 70% of adults 

who are current users of marijuana are also current users 

of tobacco (Schauer et al. 2016). Results from populationbased surveys and some clinical studies indicate an association between the use of menthol-flavored cigarettes or 

marijuana and a lower probability of successful quitting 

(Ford et al. 2002; Patton et al. 2005; Gandhi et al. 2009; 

Schauer et al. 2017). The available longitudinal evidence 

from rigorously conducted studies is limited, so it is too 

soon to determine whether this association is correlational or causal.

Developments in Approaches 

to Smoking Cessation at the 

Individual Level

This section summarizes the landmark developments 

since the 1990 Surgeon General’s report that have shaped 

treatment for tobacco dependence and corresponding 

breakthroughs in smoking cessation interventions at the 

individual level. Chapter 6 provides detailed evidence for 

current and emerging smoking cessation treatments, 

adding to the evidence presented in the Clinical Practice 

Guideline (Fiore et al. 2008). It also explores approaches 

to increasing the impact of tobacco cessation treatment 

through improved efficacy and increased reach.

Pharmacotherapy

The scientific understanding of the neurobiologic 

impact of chronic exposure to nicotine (USDHHS 2010) 

has stimulated research and development that focuses 

on identifying novel medications and improving existing 

medications. The only FDA-approved smoking cessation 

medication at the time of the 1990 Surgeon General’s 

report was the gum form of NRT (USDHHS 1990). Since 

then, several additional NRT formulations (transdermal 

patch, lozenge, inhaler, and nasal spray) have been developed, with all but the inhaler and spray now approved for 

over-the-counter sale. Additionally, FDA has approved 

two non-NRT medications for smoking cessation: bupropion and varenicline (GlaxoSmithKline 2017; FDA 2017; 

Pfizer 2019).

Adding to the progress seen for individual agents, 

favorable developments in pharmacologic treatment have 

been seen in a variety of other areas over the past two 

decades. For example, because of the modest efficacy of 

monotherapy and the recognition that persons with nicotine addiction benefit from intensive treatments, a variety 

of combination pharmacotherapies have been studied (see 

Chapter 6).

Behavioral Interventions

Discoveries in the behavioral and social sciences 

have deepened our understanding of psychosocial influences on the nature and treatment of tobacco dependence, 

which has propelled new approaches to behavioral treatment. The evidence has clarified that during and long after 

the dissipation of acute pharmacologic withdrawal from 

nicotine during cessation, several factors—including 

vacillation of negative emotional states, repeated urges 

to smoke, diminished motivation, and having less confidence in the ability to successfully quit—can persist 

throughout the cessation process and undermine quitting 

(Liu et al. 2013; Ussher et al. 2013). Furthermore, encountering environments and situations previously associated 

with smoking, such as establishments that serve alcohol 

or interacting with friends who smoke, has been demonstrated to increase risk of relapse (Conklin et al. 2013). 

Fortunately, behavioral treatment models for mental 

health conditions and other substance use disorders have 

been translated and adapted for nicotine addiction to 

address these factors and have been shown to improve quit 

rates (Hall and Prochaska 2009).

In addition to quitlines, which have been a longstanding intervention to deliver population-based behavioral smoking cessation support, technological innovations 

have opened new service delivery platforms for sophisticated behavioral cessation interventions in other modalities. In the 1990s, computer-tailored, in-depth, personalized mailings based on answers to a lengthy questionnaire 

were developed and tested on smokers; the tailored or personalized mailings were more effective than mailings with 

standard text (Prochaska et al. 1993; Strecher et al. 1994). 

Receipt of personalized written feedback and self-help 

materials was also found to increase cessation rates (Curry 

et al. 1991). A systematic review by the U.S. Preventive 

Services Task Force (USPSTF) (2015) found self-help materials that were tailored to the individual patient to be effective cessation interventions. Interactive program modalities have been developed and tested (USPSTF 2015) for 

desktop and laptop computers, first via programs operated 

from a CD-ROM or hard drive, later via Internet downloads, and more recently from “the cloud” (Strecher et 

al. 2005; Haskins et al. 2017). The current state of science 

and technology also allows the leveraging of mobile phone 

technology and applications to deliver cessation interventions (Whittaker et al. 2016). These include applications 

involving standardized motivation-enhancing texts or 

quit-promoting strategies—some of which offer real-time, 

live-peer, or professional advising or counseling within the 

application (Smokefree.gov n.d.). Preliminary evaluations 

have suggested that these applications may be beneficial 

to users (Cole-Lewis et al. 2016; Squiers et al. 2016, 2017; 

Taber et al. 2016) and that the cost of delivery is low.
A Report of the Surgeon General

18 Chapter 1

Treating Tobacco Use and Dependence

The 2000 and 2008 Clinical Practice Guidelines had 

marked impacts on increasing understanding of and operationalizing the current paradigm of treating tobacco use 

and dependence (Fiore et al. 2000, 2008). Until the 1990s, 

synopses of the state of the evidence on smoking cessation usually relied on a somewhat informal aggregation 

of clinical and population-based studies, an approach that 

is prone to author bias in the choice of studies included 

and in their interpretations. Markedly more formal review 

processes, such as systematic literature reviews, were 

applied to smoking cessation and treatment in the 1990s 

and 2000s, as thousands of cessation-related studies accumulated. These more formal reviews systematized the literature review process by using strict criteria for grading 

studies and employing meta-analyses where appropriate; 

they also included a more transparent and elaborate process for synthesizing evidentiary findings into conclusions 

and recommendations.

In addition, the standards and framing of cessation 

research have evolved over the past several decades, which 

is consistent with the increased sophistication of pharmaceutical and population-based trials in general. For 

example, clinical trials have evolved from examining the 

success rates of persons completing the trial, often examining only the point prevalence of abstinence, into using 

intent-to-treat, where all persons starting treatment are 

considered in the denominator and those lost to follow-up 

are counted as smokers or subject to data imputation techniques (Hall et al. 2001; Mermelstein et al. 2002; SRNT 

Subcommittee on Biochemical Verification 2002; Hughes 

et al. 2003; Shiffman et al. 2004). Definitions of successful 

abstinence often examine smoking status at 1  month, 

6 months, and 1 year of abstinence after treatment.

Notably, some definitions of successful abstinence 

allow for brief lapses in smoking cessation to more accurately reflect the natural course of achieving long-term 

abstinence (Zhu et al. 1996). Similarly, population-level 

surveillance and research have evolved to include increasingly more complex questions and techniques to more 

accurately capture the nature of respondents’ use of 

tobacco products and cessation behavior. For example, 

sets of questions have been developed to better categorize 

respondents’ use of healthcare services and the nature of 

cessation support they received. In addition, new technologies have been deployed to better understand the patterns 

of behavior among smokers, such as ecological momentary assessment, which cues smokers to provide data on 

their smoking urges and other thoughts, emotions, and 

behaviors in real time (Shiffman 2009). Large clinical 

trials have also examined the interplay between multiple 

factors that affect quit success, such as different medications, dual-medication therapy, and different approaches 

and intensities of behavioral interventions (Redmond 

et al. 2010).

The Clinical Practice Guidelines used formal scientific review processes to analyze thousands of studies 

produced in the 1990s and 2000s—analyses that included 

detailed evidence reviews that resulted in practical recommendations for clinicians (Fiore et al. 2000, 2008). 

Unlike most clinical guidelines, they also included recommendations at the health systems and policy levels 

based on evidence and tools designed specifically for clinicians to use in office practices. In addition, multiple 

Cochrane reviews have been performed on medications 

and counseling approaches (Hajek et al. 2013; Stead et 

al. 2013; Lindson-Hawley et al. 2015), and USPSTF has 

updated its literature on clinical preventive services (Siu 

and USPSTF 2015; USPSTF 2015). Based on the findings 

presented, the current paradigm for smoking cessation 

conceptualizes nicotine addiction as a chronic, relapsing 

disorder that benefits from long-term management and 

intensive treatment approaches, as do other chronic diseases. The major findings have shaped the way cessation 

is currently viewed:

• Any level of treatment is beneficial, and more intensive and longer behavioral and pharmacologic treatment is generally better.

• Physicians, psychologists, pharmacists, dentists, 

nurses, and numerous other healthcare professionals 

can treat nicotine addiction in smokers. Thus, by 

extension, the various settings in which such professionals work represent appropriate venues for providing these services.

• Behavioral interventions and FDA-approved pharmacotherapies are effective for treating nicotine 

dependence. A combination of behavioral interventions and pharmacotherapy is the optimal treatment 

based on overwhelming scientific evidence, with 

superiority in efficacy over either intervention alone.

Advances in research and technology have shaped 

how the clinical and scientific communities view and 

approach treatment for nicotine addiction in smokers, 

but this progress continues to lag the advances made in 

treating other chronic diseases. For instance, in cancer, 

cardiovascular disease, and other illnesses with multifactorial etiologies, major strides have been made toward precision treatment methods, which are based on the premise 

that clinical outcomes can be enhanced by selecting, 

adapting, and tailoring treatment on the basis of a patient’s 

specific clinical profile and disease pathogenesis (Collins 

and Varmus 2015). Such approaches have been endorsed 
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 19

Smoking Cessation

and promoted as part of the Precision Medicine Initiative 

(Genetics Home Reference 2018), which reinforces that the 

future of clinical care lies in basic and clinical research and 

their translation to optimize health outcomes. Although 

precision treatment has not advanced for smoking cessation at the same rate as it has for treating certain other illnesses, emerging findings suggest that a personalized, precision approach has the potential to meaningfully improve 

smoking cessation outcomes (Allenby et al. 2016).

Evolution of Approaches to 

Smoking Cessation at the 

Population Level

More Intensity Versus Higher Reach of Support 

Services

Through the first decades in which cessation interventions were developed, most of the emphasis was on 

improved efficacy—specifically, increasing the probability 

that if smokers engaged and fully used an intervention service, their chances of success would be increased. As interventions, both behavioral or pharmacologic therapies and 

combination therapies have become increasingly effective, but despite the effectiveness of such therapies, they 

are not being used as designed by substantial numbers of 

smokers (Zhu et al. 2012). Several theoretical models suggested that efforts to develop interventions need to consider their population impact, not just their individual 

efficacy for those taking part in the intervention.

In the 1990s, the potential for smoking cessation 

interventions to make an impact on the tobacco epidemic 

was overshadowed by the low rate at which smokers actually used interventions. Several factors contributed to this 

phenomenon, and several other factors initially assumed 

to be the main drivers were eliminated. One assumption 

was that smokers were just not very interested in quitting or in accessing help to quit. However, populationlevel surveys over time and among diverse populations 

showed that not only were smokers interested in quitting, 

but more than half planned to quit in the next 6 months 

and had attempted to quit in the past year (Babb et al. 

2017). In addition, when physicians or other healthcare 

providers systematically offered support for quitting, such 

as medications or follow-up, a much larger than expected 

fraction of smokers agreed to accept support. Even so, further examination revealed that helping smokers quit presented unique obstacles. Up to the 1990s,

• Almost no health insurers provided any coverage 

of smoking treatments—either medications, counseling, or physician intervention.

• Most physicians did not systematically address 

smoking in the course of clinical practice for multiple reasons, including lack of time, perception that 

patients are unready to quit, limited resources, and 

inadequate clinical skills related to cessation.

• Although smokers generally understood that 

smoking had unfavorable health effects, many did 

not fully understand or accept the magnitude or 

personal relevance of smoking’s effects on various 

aspects of health and its dramatic overall effect on 

longevity (USDHHS 1989; Chapman et al. 1993). 

Even if smokers accept the theoretical possibility 

of risk, they often do not believe that the hypothetical future risk from smoking applies to them personally—for example, they believe they have “good 

genes” or other healthy habits, or they smoke in a 

less dangerous manner (Oakes et al. 2004).

• Smokers and physicians did not realize that effective 

treatments were available.

• Even when smokers wanted to quit and were potentially interested in getting help, evidence-based treatments were not readily available to them because of 

financial and practical barriers.

Thus, during the 1980s and 1990s, a series of system 

and policy innovations were developed and tested to 

address these barriers. These innovations included the use 

of organizational system change and quality improvement 

theory to systematically address opportunities to influence smokers during routine interactions with healthcare 

systems (Solberg et al. 1990; Manley et al. 1992); experiments providing different types of insurance coverage for 

cessation treatments (Curry et al. 1998); the development 

of more easily accessible treatments, such as phone-based 

quitlines (Orleans et al. 1991; Zhu et al. 2012); integrated 

promotion of cessation via mass media campaigns that 

encouraged the use of cessation services (McAfee et  al. 

2013); and easily accessible, in-person cessation clinics 

(Lee et al. 2016).

The lack of accessibility to cessation support was 

addressed in several ways. One approach attempted to 

bypass the lack of availability of support within healthcare 

services by creating easily accessible, low-intensity cessation supports, such as telephone quitlines or in-person 

clinics, that were generally operated and funded outside the healthcare system. Another approach attempted 

to integrate very brief but systematic, repeated support 

for cessation into primary care clinical practices while 

working to obtain insurance coverage and accessibility to 

more intense services for those interested in quitting. In 
A Report of the Surgeon General

20 Chapter 1

some instances, these approaches were combined synergistically (McAfee et al. 1998). A few U.S. states and some 

other countries, such as the United Kingdom, successfully developed—through funding from tobacco tax dollars or government healthcare—networks of freestanding, 

in-person cessation clinics that provided basic cessation 

counseling and medications (Gibson et al. 2010; West et al. 

2013). However, this model has not been sustained in any 

geographic region of the United States, primarily because 

of limited resources to maintain it over time. Still, a higher 

intensity model, which includes more intensive and comprehensive cessation components, has continued to focus 

on markedly improving the chances of success by treating 

nicotine addiction via a tertiary treatment delivery model, 

akin to how a cancer center approaches patients who are 

referred for its services. For example, the Mayo Clinic and a 

handful of similar referral clinics use such strategies as indepth evaluation by multidisciplinary staff; personalized 

treatment plans; recurrent follow-up; and, in some cases, 

admission to a residential facility or hospital (Hays et al. 

2011). Although such programs often achieve high rates 

of smoking cessation, their utility is greatly limited by the 

high cost of implementation, unclear cost-effectiveness, 

and limited reach. For example, during a 7-year period, in 

a study of a large outpatient clinic, 2–3% of smokers used 

the available nicotine dependence services, even when the 

services were optimally promoted and delivered (Burke 

et al. 2015).

Population-Based Interventions

Historically, tobacco control efforts have focused 

on either helping smokers quit at the individual level, 

such as through clinical interventions, or on providing 

population-level interventions to decrease the prevalence of smoking. Potential synergies between these two 

approaches have become increasingly apparent over the 

past several decades. This section discusses four examples of attempts to combine individually delivered cessation support and population-based strategies to smoking 

cessation: quitlines, health systems transformation, mass 

media campaigns, and health insurance coverage of 

smoking cessation treatment. Chapter 7 provides a more 

in-depth review of the current literature on each of these 

topics and on other population-based interventions that 

have been shown to promote cessation, such as increasing 

the prices of tobacco products and the implementation of 

smokefree policies.

Quitlines

In the late 1980s and throughout the 1990s, researchers interested in helping large numbers of smokers 

quit smoking began to experiment with the provision of 

behavioral counseling support via telephone, in the hope 

of overcoming such barriers to utilization as cost and the 

reluctance of many smokers to attend face-to-face group 

or individual sessions. Providing counseling centrally was 

thought to provide more opportunities for systematically 

improving the quality of the counseling and the research 

infrastructures used to answer questions about the cessation process. Protocols were developed and tested in 

a variety of environments, ranging from academic centers (Ossip-Klein et al. 1991) to health systems (Orleans 

et al. 1991) to state health departments (Zhu et al. 1996). 

Multiple large, randomized trials have since established 

the effectiveness of the telephone modality (Stead et al. 

2013). The availability of quitlines grew rapidly during the 

1990s and the early 2000s.

The adoption of quitlines by state health departments 

was initially facilitated by the increased revenue provided 

to states from the Master Settlement Agreement in 1998 

and higher taxes on tobacco products. In 2003, CDC provided supplemental funding to state health departments to 

establish quitlines in those that did not have them and to 

enhance quitline services and access in those with existing 

quitlines (Zhang et al. 2016). In 2004, a national network 

of state quitlines was created with a single national portal 

number (1-800-QUIT-NOW), which is serviced by NCI 

(Cummins et al. 2007; CDC 2014b). By 2006, residents in 

all 50 states, the District of Columbia, and U.S. territories 

had access to quitlines, and the North American Quitline 

Consortium had been developed to help set evaluation standards and enhance the collection of information, including 

an agreed-upon minimum dataset to be collected from 

all callers, with a data warehouse funded by CDC (North 

American Quitline Consortium 2007; Keller et al. 2010). 

Providers of quitline services grew from modest operations 

with a few dozen employees to multiple large providers 

based in a range of organizations, including for-profit and 

nonprofit national healthcare organizations and academic 

centers, some employing hundreds of “quit coaches.” 

Mass Media Campaigns

Mass media educational campaigns on the hazards 

of smoking have been used for decades, in part to motivate quit attempts in the general population of current 

smokers, and a considerable evidence base shows their 

effectiveness in promoting successful cessation at the population level (NCI 2008; USDHHS 2014). These campaigns 

are generally thought of as being unrelated to efforts 

to provide direct assistance and support to individual 

smokers in healthcare settings or through community 

initiatives. However, since 1990, numerous efforts have 

been made to create synergies and efficiencies between 

mass media campaigns and the provision of individual 

support for quit attempts. For example, CDC’s Tips From 
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 21

Smoking Cessation

Former Smokers (Tips) media campaign features ads with 

real people (former smokers) who have suffered the health 

consequences of smoking to increase awareness of suffering caused by smoking. The ads are also tagged with a 

quitline number (CDC 2012, 2013a). Tagging the ads with 

an offer of assistance may help smokers absorb the message of the ad by making it actionable rather than simply 

negative. Chapter 7 discusses the effectiveness of mass 

media campaigns, including Tips.

Healthcare Systems

Clinic-Based Integration of Health Systems

In the 1980s, NCI funded primary care-based 

research showing that a systematic approach to addressing 

tobacco use could help individual smokers in a clinical 

practice to quit and could lower the prevalence of tobacco 

use in the population served by a clinic (Solberg et al. 

1990; Manley et al. 1992). Out of this research grew the 

“4 A’s model,” a carefully crafted intervention for transforming the approach of primary care clinics to tobacco 

cessation that was developed and packaged for widespread 

dissemination. This model differed from previous efforts 

in that it emphasized a systems approach to effectively 

address tobacco use in the context of primary care clinical practice, rather than simply developing an intervention that required for delivery its own separate healthcare or community infrastructure. The model had four 

components:

• Ask: Systematically identify the smoking status of 

all patients flowing through a practice, usually by 

an assistant interviewing the patient rather than 

relying on physician recall of patients’ smoking 

status at every visit;

• Advise: Provide at every encounter very brief, nonthreatening recommendations to quit;

• Assist: Offer practical help for quitting, including 

tips to make it through the first few weeks and brief 

supportive counseling; and

• Arrange: Ensure that any smoker planning a quit 

attempt will receive follow-up (e.g., during future 

office visits and/or through off-site resources).

Despite being shown to have significant benefits to 

smokers in clinical practices in the 1980s and 1990s, 

the adoption, implementation, and subsequent maintenance of this systematic approach was slow and uneven 

(Ferketich et al. 2006).

Based on an additional review of the evidence (Fiore 

et al. 2008), a fifth step, “Assess,” was added between the 

“Advise” and “Assist” components, thereby emphasizing 

the importance of determining a patient’s level of interest 

in quitting so that assistance and follow-up could be tailored to that person’s specific circumstances. For example, 

a brief interaction with a patient not interested in quitting 

would focus on enhancing motivation rather than providing quit advice.

The 5 A’s model is an example of an intervention 

designed to maximize the probability of a smoker making 

a quit attempt and the probability that he or she will be 

successful during such an attempt. The model seeks to 

accomplish these two tasks for a population of smokers. 

Building on the effectiveness of the 5 A’s model, the Ask, 

Advise, Refer (AAR) model was developed as a shorter 

alternative to the 5 A’s model in clinical settings where 

there is less time afforded for the patient encounter 

(Schroeder 2005). In addition, a different model, termed 

Ask, Advise, Connect (AAC) (Vidrine et al. 2013) was 

developed to ameliorate the low rate of participation 

among persons passively referred to a smoking cessation 

treatment, usually a quitline, through the AAR model. 

In the AAC model, smokers who accept the referral are 

subsequently contacted by the provider of smoking cessation treatment, typically a quitline counselor. The 

referral or connection services, such as to quitlines, have 

very strong evidence for effectiveness (Vidrine et al. 2013; 

Adsit et al. 2014) (also see Chapter 7). However, fewer 

studies have assessed the overall population impact of 

the AAR and AAC models compared with the 4 A’s and 

5 A’s models.

Although the identification of smoking status is now 

routine in most healthcare systems, providing assistance 

and follow-up to smokers occurs in only less than half of 

primary care visits (King et al. 2013; Bartsch et al. 2016). 

Health professionals have reported barriers to adopting 

and implementing these healthcare-based treatment protocols, including

• Lack of time;

• Lack of reliable reimbursement for provision of 

services;

• Lack of acceptance that addressing tobacco dependence is part of a physician’s job;

• Lack of training and/or comfort addressing problems with substance abuse;

• Lack of reliable, accessible referral resources;
A Report of the Surgeon General

22 Chapter 1

• High prevalence of smoking, meaning that even 

brief interventions significantly affect clinic flow, 

as the interventions may need to be implemented 

with a large number of patients (Vogt et al. 2005; 

Association of American Medical Colleges 2007; 

Blumenthal 2007); and 

• Privacy concerns, fear of losing patients, the discouraging belief that most patients will not be able 

to stop, and concern about stigmatizing the smoker 

(Schroeder 2005).

Responding to these issues, several professional organizations, including the American Academy of Family 

Physicians, have recommended using the AAR model at 

the clinical level to address smoking behaviors.

In recent years, increased attention has also been 

paid to the importance of building linkages between public 

health and the healthcare system and between community 

and clinical healthcare resources. This draws on the recognition that public health and healthcare stakeholders have 

complementary strengths and perspectives; that ultimately 

achieving lasting improvements in population health will 

take the combined efforts of both; and that improved coordination efforts will hasten this outcome. As part of this 

broader trend, national public health organizations and 

state tobacco control programs have begun to engage with 

healthcare systems to encourage and help them integrate 

treatment for tobacco dependence into their workflows 

(CDC 2006). Some healthcare systems have broadened the 

scope of their interventions to address upstream factors 

that shape health outcomes. For example, some healthcare systems have championed evidence-based interventions that go beyond the clinical sphere, such as smokefree 

and tobacco-free policies, increases in the price of tobacco 

products, and policies raising the age of sale for tobacco 

products to 21 years (Campaign for Tobacco-Free Kids 

2016). Predicting the evolution of cessation treatment in 

the United States and the various roles of different segments of the healthcare system is challenging because of 

the volatility and uncertain future structure of healthcare, 

especially the nature of healthcare insurance. Regardless 

of what type of delivery system emerges, efforts should 

continue to integrate evidence-based tobacco treatment 

and cessation supports into healthcare settings and expand 

those supports. This would require further embedding of 

smoking processes and outcomes in quality measures, 

adequate funding, and routinization of training. Such services could be provided in the general healthcare system, 

as well as through specialized cessation clinics. The ability 

to deliver services effectively would be aided by having sufficient geographic locations for delivering care, promoting 

services, and removing barriers to services.

Health Insurance Coverage

Comprehensive insurance coverage for evidencebased cessation treatments plays a key role in helping 

smokers quit by increasing their access to proven treatments that raise their chances of quitting successfully 

(Fiore et  al. 2008; CDC 2014a). Research in multiple 

healthcare settings in the 1990s (Curry et al. 1998) and 

2000s (Joyce et al. 2008; Hamlett-Berry et al. 2009; Smith 

et al. 2010; Fu et al. 2014; Fu et al. 2016) has demonstrated 

that comprehensive cessation coverage increases quit 

attempts, the use of cessation treatments, and successful 

quitting (Fiore et al. 2008). Accordingly, implementation 

of comprehensive cessation coverage is important in both 

private and public health insurance.

Significant milestones in the recognition that comprehensive insurance coverage for smoking cessation 

plays a key role in helping smokers quit include (a) the 

Community Preventive Services Task Force’s finding that 

reducing tobacco users’ out-of-pocket costs for proven cessation treatments increases the number of tobacco users 

who quit (Hopkins et al. 2001), and (b) the recommendation in each of the Clinical Practice Guidelines that health 

insurers cover the FDA-approved cessation treatments and 

the behavioral treatments that the Guidelines found to be 

effective (Fiore et al. 2000, 2008). These recommendations 

draw on a body of research that has documented the outcomes of insurance coverage for cessation, including its 

cost-effectiveness. This research has also helped to identify the levels of coverage that influence tobacco cessation. 

More recently, several studies have examined the utilization of cessation treatments covered by health insurance, 

especially cessation medications, and how this has changed 

over time. Initial findings from these analyses suggest that 

cessation treatments continue to be underused, especially 

among Medicaid populations, and utilization varies considerably across states (Babb et al. 2017).

Healthcare Insurance Policies

After 2010, several national levers were added to 

make tobacco use and dependence treatment a part of 

healthcare. Both Medicare and Medicaid required coverage of certain smoking cessation treatments, and the 

Affordable Care Act included several provisions that 

required non-grandfathered commercial health plans to 

provide in-network smoking cessation medications and 

counseling without financial barriers because those two 

treatments had “A” ratings from USPSTF (McAfee et al. 

2015). Even with these new regulatory levers, many 

national plans are not yet providing the required coverage 

(Kofman et al. 2012). Chapter 7 provides an in-depth discussion of private and public health insurance coverage 

for the treatment of tobacco use and dependence.
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 23

Smoking Cessation

E-Cigarettes: Potential Impact on 

Smoking Cessation

E-cigarettes (also called electronic nicotine delivery 

systems [ENDS], vapes, vape pens, tanks, mods, and podmods) are battery-powered devices designed to convert a 

liquid (often called e-liquid)—which contains a humectant 

(propylene glycol and vegetable glycerin) and also typically 

contains nicotine, flavorings, and other compounds—

into aerosol for inhalation by the user. First introduced 

in the United States in 2007 (USDHHS 2016), the advent 

of e-cigarettes into the tobacco product marketplace was 

seen by some as a potential harm-reduction tool for current adult smokers if the products were used to transition 

completely from conventional cigarettes (Fagerstrom et al. 

2015; Warner and Mendez 2019). E-cigarette aerosol has 

been shown to contain markedly lower levels of harmful 

constituents than conventional cigarette smoke (National 

Academies of Sciences, Engineering, and Medicine 2018). 

Accordingly, interest remains in policies and approaches 

that could maximize potential benefits of these devices 

while minimizing potential pitfalls posed by the devices at 

the individual and population levels, including concerns 

about initiation among young people. The 2016 Surgeon 

General’s report, E-Cigarette Use Among Youth and Young 

Adults, examined many aspects of e-cigarettes related to 

young people; however, it did not address the potential 

impact of e-cigarettes on smoking cessation among adult 

smokers (USDHHS 2016). It is also important to note that 

the landscape of available e-cigarette products has rapidly 

diversified since their introduction in the United States in 

2007, including the introduction of “pod mod” e-cigarettes 

that have dominated the e-cigarette marketplace in recent 

years (Barrington-Trimis and Leventhal 2018; Office of the 

U.S. Surgeon General n.d.). This section highlights salient 

issues about how e-cigarettes may influence cessation, 

which is reviewed in more depth in Chapter 6.

Implications of E-Cigarette Characteristics for 

Smoking Cessation

Nicotine delivery through inhalation, as is the case 

with cigarette smoking, results in rapid nicotine absorption and delivery to the brain. The pharmacokinetics of 

nicotine delivery varies across products and is influenced 

by user topography, with some, but not all, e-cigarette 

products providing nicotine delivery comparable to conventional cigarettes (National Academies of Sciences, 

Engineering, and Medicine 2018). By contrast, the nicotine 

inhaler, one of several FDA-approved NRTs, delivers nicotine primarily through the buccal mucosa; it is designed 

to reduce nicotine withdrawal and cravings while minimizing abuse liability (Schneider et al. 2001). For smokers 

of conventional cigarettes who seek a product with a rapid 

delivery of nicotine similar to cigarettes, e-cigarettes that 

deliver nicotine in a similar way to cigarettes may have 

greater appeal than NRTs. Although rapid boluses of nicotine could increase the appeal, as well as addiction and 

potential greater abuse liability, of e-cigarettes relative 

to NRTs, whether this pharmacokinetic profile produces 

an effective method of cessation is presently inconclusive 

from the emerging base of empirical evidence (Shihadeh 

and Eissenberg 2015).

Other features of e-cigarettes that may enhance their 

appeal to smokers of conventional cigarettes include the 

ways in which they mirror some of the sensorimotor features of conventional cigarette smoking, including stimulation of the airways, the sensations and taste of e-cigarette 

aerosol in the mouth and lungs, the hand-to-mouth movements and puffing in which e-cigarette users engage, and 

the exhalation of aerosol that may visually resemble cigarette smoking. Given the potentially important role of 

such sensorimotor factors in the reinforcing and addictive 

qualities of conventional cigarettes (Chaudhri et al. 2006), 

the presence of these attributes could make e-cigarettes 

more appealing to smokers as a substitute for cigarettes 

than NRTs because the NRTs either lack such sensorimotor features (e.g., the transdermal patch, nicotine gum) 

or offer only partial approximations (e.g., the inhaler).

However, when considering e-cigarettes as a potential cessation aid for adult smokers, it is also important to 

take into account factors related to both safety and efficacy. 

NRT has been proven safe and effective, but there is no 

safe tobacco product. Although e-cigarette aerosol generally contains fewer toxic chemicals than conventional cigarette smoke, all tobacco products, including e-cigarettes, 

carry risks.

As noted in the 2016 Surgeon General’s report, many 

of the characteristics that distinguish e-cigarettes from conventional cigarettes increase the appeal of these new products to youth and young adults, particularly nonsmokers 

(USDHHS 2016). These factors include appealing flavors, 

high concentrations of nicotine, concealability of use, 

and widespread marketing through social media promotion and other channels (Barrington-Trimis and Leventhal 

2018). Many e-cigarettes differ markedly in shape and feel 

compared with conventional cigarettes; e-cigarettes come 

in a variety of shapes, including rectangular tank-style 

and USB-shaped devices (as discussed in Chapter  6 and 

shown in Figure 6.1). For example, JUUL, the top-selling 

e-cigarette brand in the United States in 2018 (Wells Fargo 

Securities 2018), is shaped like a USB flash drive and offers 

high concentrations of nicotine in the cartridges, which 

are also known as “pods” (Huang et  al. 2018). Notably, 

the novelty, diversity, and customizability of e-cigarettes 

appeal to youth (Chu et al. 2017; Office of the U.S. Surgeon 
A Report of the Surgeon General

24 Chapter 1

General n.d.). For example, there are numerous scientific reports documenting the appeal of, and dramatic rise 

in, JUUL use among youth and young adults (Chen 2017; 

Teitell 2017; Beal 2018; Bertholdo 2018; Coughlin 2018; 

Grigorian 2018; Saggio 2018; Suiters 2018; FDA 2018; 

Willett et al. 2018; Radding n.d.).

Of note, a growing number of e-cigarettes, including 

JUUL, also use nicotine salts, which have a lower pH than 

the freebase nicotine used in most other e-cigarettes and 

traditional tobacco products, and allow particularly high 

levels of nicotine to be inhaled more easily and with less 

irritation. Although this type of product may be appealing 

to adult smokers seeking e-cigarettes with potentially 

greater nicotine delivery, the potency and appeal of such 

products can also make it easier for young people to initiate the use of nicotine and become addicted (Office of the 

U.S. Surgeon General n.d.).

The final chapter of the 2014 Surgeon General’s 

report concluded that the use of e-cigarettes could have 

both positive and negative impacts at the individual and 

population levels (USDHHS 2014). One of its conclusions 

was that “the promotion of noncombustible products is 

much more likely to provide public health benefits only in 

an environment where the appeal, accessibility, promotion, 

and use of cigarettes and other combusted tobacco products are being rapidly reduced” (USDHHS 2014, p. 874). 

Therefore, it is important to continue (a)  monitoring 

the findings of research on the potential of e-cigarettes 

as a smoking cessation aid and (b) evaluating the positive 

and negative impacts that these products could have at 

the individual and population levels, so as to ensure that 

any potential benefits among adult smokers are not offset 

at the population level by the already marked increases 

in the use of these products by youth. It is particularly 

important to evaluate scientific evidence on the impact 

of e-cigarettes on adult smoking cessation in the current context of the high level of e-cigarette use by youth, 

which increased at unprecedented levels in recent years 

following the introduction of JUUL and other e-cigarettes 

shaped like USB flash drives (Cullen et al. 2019).

Summary

Once erroneously considered a habit that could be 

broken by simply deciding to stop, nicotine addiction is 

now recognized as a chronic, relapsing condition. The 

prevalence of cigarette smoking in the United States has 

declined steadily since the 1960s; however, as of 2017, 

there were still more than 34 million adult current cigarette smokers in the United States (Wang et al. 2018).

Proven smoking cessation treatments are widely 

available today. However, the reach and use of existing 

smoking cessation interventions remain low, with less than 

one-third of smokers using any proven cessation treatments (behavioral counseling and/or medication) (Babb 

et al. 2017). A majority of smokers still attempt to quit 

without using such treatments, contributing to a failure 

rate in excess of 90% (Hughes et al. 2004; Fiore et al. 2008).

Medications and behavioral interventions with 

increasing levels of efficacy and sophistication are becoming 

more widely available, but there is considerable room for 

improvement. Further, the challenge of getting behavioral 

and pharmacologic interventions to be used concurrently 

and disseminated more broadly to the public has only been 

partially solved.

Full integration of treatment for nicotine dependence into all clinical settings—including primary and 

specialty clinics, hospitals, and cancer treatment settings—can benefit from increases in barrier-free health 

insurance coverage. Combining health service systems 

and electronic media platforms for the delivery of smoking 

cessation interventions has emerged as one promising 

method to increase reach of smoking cessation treatment 

to smokers (e.g.,  evidence-based cessation interventions 

using phone lines and mobile phone applications, and 

use of electronic health records to promote more timely 

referral to cessation support services). Barrier-free health 

insurance coverage (e.g.,  copays, coverage limits, prior 

authorization) and access to services, coupled with the 

use of quality improvement metrics and methodologies, 

have been shown to increase smokers’ use of evidencebased services.

Clinical-, system-, and population-level strategies are 

increasingly taking a more holistic approach to decreasing 

the prevalence of smoking, with interventions designed to 

increase quit attempts and enhance the chances of success. 

Examples include the national Tips From Former Smokers

media campaign, which used ads featuring smokers who 

had suffered tobacco-related morbidity to increase awareness of individual suffering caused by smoking while simultaneously enhancing the capacity of the national quitline 

network to respond to upsurges in calls that were generated by tagging the ads with the phone number for the quitline. Millions of smokers made quit attempts as a result of 

exposure to the ads, and hundreds of thousands have successfully quit smoking. In addition, the development and 

dissemination of the carefully crafted and research-tested 

5 A’s model in healthcare settings, combined with public 

and private policy changes that encourage coverage of cessation, have systematically encouraged more smokers to 

try to quit and provided them with evidence-based support. Still, the potential of mass media campaigns, quitlines, and clinical support has been tapped only partially, 

leaving many opportunities for further adoption, dissemination, and extensions of these approaches.
Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation 25

Smoking Cessation

Use of e-cigarettes could have varied impacts on different segments of the population, including potential 

benefits to current adult cigarette smokers who transition 

completely; however, potential efficacy may depend on 

many factors, such as type of devices and e-liquids used, 

reason for use, and duration of use. Well-controlled, randomized clinical trials and rigorous, large-scale observational studies with long-term follow-ups will be critical to 

better understand the impact of e-cigarettes on cessation 

under various conditions and settings. Nevertheless, the 

potential benefit of e-cigarettes for cessation among adult 

smokers cannot come at the expense of escalating rates of 

use of these products by youth. Accordingly, the current 

science base supports a number of actions to minimize 

population risks while continuing to explore the potential utility of e-cigarettes for cessation, including efforts 

to prevent e-cigarette use among young people, regulate 

e-cigarette products and marketing, and discourage longterm use of e-cigarettes as a partial substitute for conventional cigarettes rather than completely quitting.
A Report of the Surgeon General

26 Chapter 1

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