577

Chapter 7

Clinical-, System-, and Population-Level Strategies 

that Promote Smoking Cessation

Introduction 579

Literature Review Methods 579

Clinical- and Health System-Based Strategies on Smoking Cessation 581

Clinical Practice Guidelines 583

Clinical Practice Guideline from the U.S. Public Health Service 583

Recommendations from the U.S. Preventive Services Task Force 586

Improving and Promoting Coverage of Treatment for Tobacco Use and Dependence 587

Health Insurance Coverage 588

Removing Barriers to Access 592

Promoting Coverage for Utilization of Smoking Cessation Treatments and Benefits 594

Quality and Performance Measures and Payment Reforms 594

Linking Quality Measures to Payment 595

Health Plan-Based Quality Measures 595

Hospital-Based Performance Measures 595

Realigning Payment Incentives 596

Enhancing the Technology of Electronic Health Records 597

Population-Based Strategies on Smoking Cessation 598

Quitlines 598

Increasing the Price of Tobacco Products 599

Smokefree Policies 601

Mass Media Campaigns 603

Examples of Campaigns 603

Features of Antismoking Campaigns that Support the Use of Cessation Resources 604

Effectiveness of Campaigns 605

State Tobacco Control Programs 605

Pictorial Health Warnings 607

Plain Packaging 608

Reduced Retail Point-of-Sale Advertising and Retail Density 609

Restricting the Sale of Certain Types of Tobacco Products 610

Very-Low-Nicotine-Content Cigarettes 612

E-Cigarettes 612

Modeling to Assess the Impact of Policy and Regulatory Changes on Cessation 613

Limitations and Methodologic Gaps 617

Summary of the Evidence 618

Conclusions 619

References 620

Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 579

Smoking Cessation

Introduction

Clinical-, system-, and population-level strategies 

can broadly influence the behavior of smokers as they try to 

quit or think about quitting smoking. This chapter focuses 

on these broad strategies that can facilitate the integration of individual components of treatment for smoking 

cessation, as discussed in Chapter  6, into routine clinical care—making cessation interventions available and 

accessible to individual smokers and creating conditions 

whereby smokers become aware of these interventions and 

are motivated to use them. This chapter does not attempt 

to provide a review of all tobacco control policy actions 

that may result in smokers attempting to quit or that 

may increase quit success outside the context of cessation 

treatment interventions; these have been covered comprehensively in previous Surgeon General’s reports, including 

the 50th  anniversary report, The Health Consequences 

of Smoking—50  Years of Progress (U.S. Department of 

Health and Human Services [USDHHS] 2014), as well as 

in other documents (National Cancer Institute [NCI] and 

World Health Organization [WHO] 2017; WHO 2019). 

Table  7.1 describes key findings from the 2014 Surgeon 

General’s report that are relevant to smoking cessation.

Strategies that encourage smoking cessation beyond 

the individual smoker generally involve actions at one of 

three levels: (1) the clinical setting, (2) the health system, 

or (3)  the population. Actions taken at the clinical and 

health system levels typically target quitting behavior 

directly and generally focus on the use or effectiveness 

of treatments for smoking cessation (Fiore et  al. 2008; 

Centers for Disease Control and Prevention [CDC] 2014b; 

U.S. Preventive Services Task Force [USPSTF] 2015). 

These actions include implementing policies that transform systems of care to better address tobacco use and 

dependence; promoting evidence-based treatments for 

tobacco cessation; and implementing policies that are 

clinically focused, address health insurance coverage, 

and promote cessation. These actions can reach a large 

proportion of Americans who smoke, considering nearly 

70% of U.S. adults who smoke cigarettes visit a primary 

care clinician each year (CDC 2012c) and millions of U.S. 

adults see specialty clinicians and are hospitalized annually (National Center for Health Statistics 2018).

In contrast, population-based strategies are aimed 

at influencing tobacco cessation at a macro level by motivating smokers to quit and by providing an environment 

that supports or simplifies efforts to quit or lowers barriers that smokers might encounter. These strategies 

are broader than those at the clinical or health system 

levels, affecting the larger community or population, 

not just individuals engaged with the healthcare system. 

Population-based strategies include increasing the price 

of and/or the tax on cigarettes and other tobacco products; restricting where tobacco can be used by implementing smokefree and tobacco-free policies; adequately 

funding tobacco control programs at the state level; carrying out mass media campaigns (e.g., CDC’s Tips From 

Former Smokers campaign [Tips] [CDC 2018b] and the 

U.S. Food and Drug Administration’s [FDA’s] Real Cost 

Campaign [FDA 2018b]); making changes to the tobacco 

retail density and point-of-sale environments; and developing product regulations, including regulating nicotine content and requiring pictorial health warnings. 

Importantly, combining clinical and health system-based 

and macro-level strategies can have a synergistic effect 

on improving cessation outcomes. For example, in addition to motivating smokers to make a quit attempt, a 

mass media campaign (a macro-level strategy), such as 

the Tips campaign, can motivate smokers to use cessation resources, including state quitlines, web-based cessation support, and cessation interventions from healthcare 

providers.

This classification of strategies to promote smoking 

cessation is similar to CDC’s “three buckets framework,” 

in which prevention approaches include (1)  traditional 

patient-level clinical interventions; (2)  innovative clinical prevention provided outside of the clinical or health 

system setting; and (3)  population- or community-wide 

interventions that reach a broader population, often 

defined geographically (Auerbach 2016) (Figure 7.1). With 

this framework in mind, a combination of strategies across 

the three buckets could potentially provide optimal cessation motivation and support for smokers by helping them 

quit and creating a broad environment that is conducive 

to and supportive of quitting.

Literature Review Methods

For the evidence presented in this chapter, PubMed/

Medline, Scopus, and Google Scholar were searched for 

studies that focused on smoking cessation policies as 

they are impacted by various strategies, technologies, and 

inducements at both the health system and population 

levels, with a specific focus on well-designed review articles 
A Report of the Surgeon General

580 Chapter 7

and meta-analysis, when available. Articles were published 

between January  1, 2002, and December  31, 2016, and 

included references to other sources (e.g., those in Clinical 

Practice Guideline [Fiore et al. 2008]) that predated 2002. 

Consistent with the longstanding process adhered to for 

the development of Surgeon General’s reports on tobacco 

(see Chapter 1), several additional studies published after 

2016 were added during the review and clearance process 

to ensure that the volume includes the most updated scientific literature available. A combination of keywords 

and phrases were used in conjunction with “cessation” or 

“quit” to investigate the following topics as they relate to 

smoking cessation: (1) clinic and health system strategies, 

including guidelines, insurance coverage, provider payments/incentives, performance measures, and electronic 

health records (EHRs); and (2)  population-based policies, including tobacco taxes/price, quitlines, mass media 

campaigns, smokefree strategies, tobacco control programs, pictorial health warnings, plain packaging, retail 

density, low-nicotine-content cigarettes, and menthol or 

flavors. Chapter conclusions reflect evidence cited in previous Surgeon General’s reports and newly available evidence. Search results were limited to studies published in 

English and to original research.

Table 7.1 Summary of policies from the 2014 Surgeon General’s report that encourage smoking cessation

Policy area Results for smoking cessation

Tax or price • A 10% increase in cigarette price is associated with a 3–5% decrease in cigarette consumption.

• Increasing the price of tobacco products reduces initiation, prevalence, and intensity of smoking in 

youth and adults.

Smokefree policies In addition to protecting nonsmokers from exposure to secondhand smoke, strong evidence suggests 

that smokefree laws and policies:

• Reduce the prevalence of tobacco use,

• Increase the number of tobacco users who quit, and

• Reduce the initiation of smoking among youth and young adults.

Specifically, smokefree laws and policies are associated with a:

• 3.4% reduction in the prevalence of tobacco use, and

• 6.4% increase in tobacco cessation.

Healthcare policies Federal regulations and legislation have included components to increase the delivery of evidence-based 

treatments for nicotine dependence in healthcare systems:

• The HITECH Act requires the identification and documentation of tobacco use in the EHRs of all patients 

13 years of age and older who use tobacco. This has made the identification and documentation of tobacco 

use in EHRs nearly universal in the U.S. healthcare system.

• The ACA contains several tobacco cessation elements:

– Mandatory coverage for tobacco cessation medications in state Medicaid programs;

– Coverage, without cost sharing, of treatment for nicotine dependence for pregnant smokers in state 

Medicaid programs; and

– The elimination of copayments for preventive services rated A or B by USPSTF, including nicotine 

dependence treatment for all adults.

• In 2010, Medicare expanded coverage of tobacco cessation to all beneficiaries who use tobacco, replacing 

previous coverage limited to beneficiaries with signs or symptoms of a tobacco-related disease.

Comprehensive 

statewide tobacco 

control programs

States that have invested more funds in tobacco control have seen larger and faster declines in the 

prevalence of smoking. Several elements have been shown to be effective at promoting and facilitating 

tobacco cessation:

• Mass media health communications designed to discourage initiation and encourage cessation among 

youth. For example, CDC’s Tips campaign motivated an estimated 1.6 million additional smokers to 

make a quit attempt.

• Healthcare system- and population-based interventions encouraged by state programs can promote 

tobacco cessation via increased delivery of evidence-based tobacco use treatments, such as:

– Tobacco cessation quitlines and

– Evidence-based tobacco cessation programs housed in healthcare delivery systems.

Source: USDHHS (2014).

Notes: ACA = Patient Protection and Affordable Care Act; CDC = Centers for Disease Control and Prevention; EHRs = electronic health 

records; HITECH Act = Health Information Technology Economic and Clinical Health Act; USPSTF = U.S. Preventive Services Task Force.
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 581

Smoking Cessation

One hundred sixty-five articles were initially identified for review for this chapter, with additional literature added that was published following completion 

of the initial literature review. For the first section on 

clinical and health system-based strategies, 75  articles 

were initially reviewed. These articles fell into the following categories: clinical guideline training and compliance (15  articles), provider and health system payments/incentives (22  articles), performance measures 

(4 articles), health information technology (12 articles), 

insurance coverage and benefits (13 articles), and health 

system enhancements (9 articles). For the second section 

on population-based strategies, 90 articles were initially 

reviewed. These articles fell into the following categories: 

tobacco taxes/price (19  articles), quitlines (16  articles), 

EHR enhancement (3  articles), mass media campaigns 

(16 articles), smokefree policies (17 articles), and pictorial health warnings (5 articles). Subsequent to the initial 

review, additional reviews were performed that identified 

articles on the following categories: tobacco control programs, plain packaging, retail density and point-of-sale 

advertising, and flavor and product restrictions. Each 

article was screened for level of relevance to the topic, 

its recency, whether it provided novel or complementary 

information (relative to other articles), and the quality 

and soundness of its experimental methods given the 

goals of the research. Articles that did not meet these criteria were excluded. 

Figure 7.1 CDC’s conceptual population health and prevention framework

Source: Auerbach (2016), with permission.

Clinical- and Health System-Based Strategies on Smoking Cessation

Although significant progress has been made to 

integrate tobacco use and dependence treatment into 

clinical health systems, substantial opportunities remain 

for improvement. For example, in 2000, 52.4% of cigarette smokers who had seen a health professional during 

the previous year reported that they had received advice 

to quit. In 2015, that figure rose to 57.2% (Babb et al. 

2017). This suggests that progress on this indicator has 

been slow, with more than 40% of smokers in healthcare 

settings not receiving basic tobacco cessation counseling 

from clinicians. Moreover, the rates at which physicians 

deliver more intensive interventions, such as cessation 

assistance and follow-up to help persons plan for and carry 

out quit attempts, are typically lower than the prevalence 

of screening for tobacco use and delivering advice to quit 

(King et al. 2013b; Bartsch et al. 2016); these more intensive steps can play an important role in helping smokers 

carry out quit attempts (Fiore et al. 2008).

One way to increase smoking cessation interventions from clinicians is through health systems policies 

and protocols that make smoking cessation a standard 

of care (Fiore et al. 2008). Systemwide strategies and 

changes can increase the delivery of clinical cessation 

interventions by routinizing the approach to smoking cessation, making it easier for clinicians and their teams to 

consistently provide evidence-based cessation treatments 

(Fiore et al. 2007; Rigotti 2011; CDC 2014a). In particular, 

data and experiences from the field suggest that health 
A Report of the Surgeon General

582 Chapter 7

systems initiatives are most likely to increase the prevalence of clinical cessation interventions if these initiatives 

(a) embed policies and protocols for tobacco use screening 

and intervention into the clinical workflow, including provider reminder systems and support for clinical decisions; 

(b) embed decision support tools into health records, 

including EHRs1; and (c) delegate specific components of 

the intervention to the broader healthcare team to reduce 

the burden on time-constrained physicians (Fiore et al. 

2008; Lindholm et al. 2010; Land et al. 2012; Jansen et al. 

2014; Moody-Thomas et al. 2015; Smith et al. 2015).

However, evidence is mixed on the impact of health 

systems change on overall cessation. For example, a 2017 

Cochrane Review assessed the effectiveness of systems 

change interventions in healthcare settings for increasing 

smoking cessation and/or the provision of cessation care 

(Thomas et al. 2017). Evidence from the review indicated 

that systems change interventions improve performance 

on process outcomes, such as documenting smoking 

status and providing cessation counseling and treatment, 

but these interventions do not yet clearly demonstrate 

that they increase cessation rates. Conversely, a 2012 study 

of data from more than 100,000 patients in the Harvard 

Vanguard Medical system during 2005–2010 found that 

patients in clinics that implemented a systems change 

approach (defined as using a tobacco use identification 

system and screening at least half of all patients) had significant reductions in the prevalence of smoking and in the 

rate of office visits for smoking-related disease (Land et al. 

2012).

Chapter 6 details the specific barriers that clinicians 

may face when delivering smoking cessation interventions 

to patients, along with approaches to overcoming these 

barriers. Barriers include time constraints, insufficient 

training on tobacco dependence and treatment, lack of 

confidence among clinicians on their ability to effectively 

deliver cessation interventions, a perception on the part 

of some clinicians that tobacco dependence treatment 

is not effective, limited clinician time and reimbursement to provide treatment to patients, and failure to fully 

engage other clinical staff in providing cessation support 

to patients (Rojewski et al. 2019). Many of these individual 

barriers can be overcome by implementing the systemwide policies discussed in this chapter.

In addition to strategies that seek to make the 

delivery of smoking cessation interventions in health systems more routine, those that remove cost and other barriers (which impede smokers’ access to proven cessation 

treatments) have been shown to increase the delivery and 

utilization of tobacco dependence treatment, especially 

when the covered treatments are proactively promoted 

to health plan beneficiaries. For example, standardized 

comprehensive, barrier-free cessation coverage by private 

and public insurers expedites smokers’ access to evidencebased cessation treatments and removes confusion about 

which treatments are covered and related barriers for both 

smokers and providers, thereby increasing the chances 

that smokers and providers will make use of these treatments (Fiore et al. 2008; Kofman et al. 2012; CDC 2014b). 

Clinical guidelines and clinical quality measures also play 

an important role in ensuring that clinicians and health 

systems consistently intervene with tobacco users (Ward 

et al. 2003; Katz et al. 2004, 2014; Lesho et al. 2005; Smith 

et al. 2005, 2008; Caplan et al. 2011; Moody-Thomas et al. 

2011; Shelley et al. 2011; Fiore et al. 2012; Kruger et al. 

2015; Siu 2015).

During the past decade, numerous policy and regulatory efforts at the national, state, and local levels have been 

undertaken in the United States to encourage clinicians 

and health systems to identify, document, and treat persons who use tobacco (USDHHS 2014; McAfee et al. 2015; 

Fiore 2016; Thomas et al. 2017) and to encourage health 

insurers to cover smoking cessation and to promote the 

covered treatments. Generally, these efforts have focused 

on achieving several goals, including (1)  increasing 

rates of cessation; (2)  improving smokers’ awareness of 

and access to evidence-based treatments; (3)  improving 

patient health and healthcare quality; (4) reducing healthcare costs associated with tobacco use; (5)  identifying 

and promoting evidence-based cessation treatments and 

programs; (6) establishing clinical standards for tobacco 

use and dependence treatment and making clinicians and 

health systems aware of such standards; (7) improving cessation insurance coverage and promoting it to smokers; 

(8) enhancing compensation for providers or health systems through pay-for-performance quality measures, payment reforms, and improved, simpler reimbursement procedures; and (9) leveraging health information technology 

to improve and routinize treatment for tobacco use and 

dependence (CDC 2014b; USDHHS 2014; McAfee et  al. 

2015; Fiore 2016).

Achieving these goals involves taking action at multiple levels and may involve government (at the local, 

state, and/or national levels) and nongovernmental entities (e.g.,  accreditation and nonprofit organizations, 

health system administrators, and insurers). This section 

1An EHR is a collection of health-related information for a patient that is generated by one or more visits in any healthcare setting. The 

EHR typically includes demographic information about the patient, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. EHRs focus on the total health of the patient and thus go beyond the standard clinical data that are collected in a healthcare provider’s office, offering a broader view of the patient’s care.
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 583

Smoking Cessation

describes the major types of strategies at the clinical and 

health system levels and the evidence regarding their 

effects on cessation interventions. Because some of the specific strategies were developed relatively recently (McAfee 

et  al. 2015; Fiore 2016), their effects on key endpoints, 

including increased access to clinical services for cessation 

and higher rates of cessation, are not yet fully known.

Clinical Practice Guidelines

Clinical practice guidelines from a variety of entities, including governmental, professional, and accrediting agencies, are relevant to clinical and health system 

policies in two ways. First, they contain best-practice recommendations for clinical treatment that are based on scientific evidence. As such, clinical practice guidelines can 

increase the likelihood that clinicians will use evidencebased approaches to help their patients quit using tobacco. 

Second, such guidelines seek to integrate evidence-based 

cessation interventions into routine clinical practice, 

serving as standards and laying the groundwork for the 

effective implementation of other policy levers, including 

insurance coverage policies and performance quality measures. Two examples of clinical practice guidelines will be 

described in this report—Clinical Practice Guidelines from 

the U.S. Public Health Service (Fiore et al. 2008) and the 

recommendations from the U.S. Preventive Services Task 

Force (USPSTF 2015). However, there are other guidelines, position statements, and consensus statements from 

a variety of organizations regarding the clinical treatment of tobacco use disorder (e.g., American Psychiatric 

Association 2010; Larzelere and Williams 2012; American 

Academy of Family Physicians 2014; Farber et  al. 2015; 

Barua et al. 2018).

Clinical Practice Guideline from the U.S. Public 

Health Service

The U.S. Public Health Service first published in 

1996 its Clinical Practice Guideline Treating Tobacco 

Use and Dependence (Fiore et al. 1996) and updated it in 

2000 (Fiore et al. 2000) and 2008 (Fiore et al. 2008) (also 

discussed in Chapter 1). The Clinical Practice Guideline 

reviews extensive evidence indicating that health system 

changes can improve the delivery of treatment for smoking 

cessation in healthcare settings and can lead to improved 

downstream quitting behavior and quitting outcomes. 

Importantly, the findings and recommendations of the 

Clinical Practice Guideline are broadly applicable across 

most clinical settings, including primary care, specialty, 

and inpatient settings; dental care settings; and behavioral 

health settings (Hall et al. 1998; Hayford et al. 1999; Smith 

et al. 2003; Wagena et al. 2005; Gordon et al. 2006, 2007, 

2010). Moreover, the Clinical Practice Guideline recommends specific changes in healthcare systems and policies to enhance the delivery of cessation interventions in 

clinical settings (Fiore et al. 2008). Table 7.2 describes the 

systems and policy findings of the 2008 Clinical Practice 

Guideline and the evidence base supporting them.

The Clinical Practice Guideline (Fiore et al. 2008) 

identified (a)  specific health system strategies and policies that can facilitate or complement clinical treatments 

for smokers who visit healthcare settings and (b) strategies that can enhance the likelihood that smokers receive 

evidence-based treatments for tobacco use and dependence and/or subsequently quit tobacco use. For example, 

the Clinical Practice Guideline found meta-analytic evidence that training clinicians increases the likelihood 

that they will provide cessation treatment (odds ratio 

[OR] = 3.2; 95% confidence interval [CI], 2.0–5.2) and that 

such training is associated with subsequent increases in 

cessation among their patients (OR = 2.0; 95% CI, 1.2–

3.4). Similarly, in a Cochrane Review of training health 

professionals to conduct interventions in smoking cessation, Carson and colleagues (2012) concluded that clinicians who received training were more likely than 

untrained clinicians (control group) to ask patients to set 

a quit date, make follow-up appointments, and counsel 

smokers. However, in general, clinicians’ follow-up with 

patients who are trying to quit remains suboptimal (King 

et al. 2013b; Bartsch et al. 2016).

Additionally, as outlined in Table 7.2, meta-analytic 

evidence from the Clinical Practice Guideline found that 

implementing systems to identify the smoking status of 

patients further increases clinicians’ rates of intervention 

with patients (nine studies: OR  =  3.1; 95% CI, 2.2–4.2) 

(Fiore et  al. 2008). Because the prevalence of cigarette 

smoking remains high in certain subpopulations in the 

United States, such as persons of lower socioeconomic 

status (Wang et al. 2018) and those with comorbid mental 

health and other substance use diagnoses (Substance 

Abuse and Mental Health Services Administration 2013), 

specific types of healthcare providers or clinical environments that serve these subpopulations (e.g., psychiatrists, 

psychologists, social workers, federally qualified health 

centers) will likely play an increasingly important role in 

tobacco cessation.

Systems-level recommendations contained in the 

2000 and 2008 Clinical Practice Guidelines have influenced numerous public and private sector policies and recommendations for treating tobacco use and dependence 

and have also served as the evidentiary basis for healthcare legislation (Torrijos and Glantz 2006). For example, 

evidence from the Clinical Practice Guidelines helped to 

inform cessation provisions in the 2010 Patient Protection 
A Report of the Surgeon General

584 Chapter 7

Table 7.2 Systems-level changes reviewed in the 2008 Clinical Practice Guideline to encourage smoking cessation

Strategy Action Strategies for implementation

Meta-analytic findings from the 

2008 Clinical Practice Guideline

1. Implement a 

tobacco user 

identification 

system in 

every clinic

Implement an 

officewide system to 

ensure that tobacco use 

status is queried and 

documented for every

patient at every visit 

to the clinic

• Office system change: Expand 

the review of vital signs to 

include tobacco use or implement 

an alternative universal 

identification system

• Responsible staff (nurse, medical 

assistant, receptionist, or other 

person already responsible for 

recording the vital signs): Must 

be instructed on the importance 

of this activity and serve as 

nonsmoking role models

• Frequency of utilization: Every 

visit for every patient, regardless 

of the reason for the visit

• System-implementation steps: 

Routine smoker identification 

can be achieved by modifying data 

collection and documentation 

in EHRs to include tobacco use 

status as one of the vital signs

• Impact of having a tobacco use 

status identification system in place 

on rates of clinician intervention 

with their patients who smoke 

(n = 9 studies): OR = 3.1; 95% CI, 

2.2–4.2

• Impact of having a tobacco use 

status identification system in place 

on abstinence rates among patients 

who smoke (n = 3 studies): OR = 2.0; 

95% CI, 0.8–4.8

2. Provide education, 

resources, and 

feedback to promote 

interventions 

by healthcare 

providers

Healthcare systems 

should ensure that 

clinicians have 

sufficient training 

to treat nicotine 

dependence; that 

clinicians and patients 

have resources; 

and that clinicians 

are given feedback 

about their nicotine 

dependence treatment 

practices

• Educate all staff on a regular basis 

by offering training (e.g., lectures, 

workshops, in-services) on nicotine 

dependence treatments and 

providing continuing education 

credits and/or other incentives 

for participation

• Provide resources—such as 

having ready access to tobacco 

quitlines (800-QUIT-NOW 

and www.smokefree.gov) and 

establishing a tobacco quitline 

referral system—and other 

community resources, self-help 

materials, and information about 

effective tobacco use medications

• Report the provision of nicotine 

dependence interventions on 

performance measures, report 

cards, and evaluative standards for 

healthcare organizations, insurers, 

accreditation organizations, and 

physician group practices

• Provide feedback to clinicians about 

their performance, drawing on data 

from EHRs and quality reporting 

programs, and evaluate the degree 

to which clinicians are identifying, 

documenting, and treating patients 

who use tobacco

• Effectiveness of clinician training 

on asking about smoking status 

(“Ask”) (n = 3 studies): OR = 2.1; 

95% CI, 1.9–2.4

• Effectiveness of training on setting 

a quit date (“Assist”) (n = 2 studies): 

OR = 5.5; 95% CI, 4.1–7.4

• Effectiveness of training on rates 

of providing treatment (“Assist”) 

(n = 2 studies): OR = 3.2; 95% CI, 

2.0–5.2

• Effectiveness of training on 

providing materials (“Assist”) 

(n = 2 studies): OR = 4.2; 95% CI, 

3.4–5.3

• Effectiveness of training on 

arranging for follow-up (“Arrange”) 

(n = 2 studies): OR = 2.7; 95% CI, 

1.9–3.9

• Effectiveness of training on 

abstinence rates (vs. no training) 

(n = 2 studies): OR = 2.0; 95% CI, 

1.2–3.4
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 585

Smoking Cessation

Strategy Action Strategies for implementation

Meta-analytic findings from the 

2008 Clinical Practice Guideline

3. Dedicate staff to

provide nicotine

dependence

treatment and

assess the delivery

of this treatment

in the performance

evaluations of staff

Clinical sites should 

communicate to all 

staff the importance 

of intervening with 

tobacco users and 

should designate a staff 

person (e.g., nurse, 

medical assistant, or 

other clinician) to 

coordinate nicotine 

dependence treatments.

Nonphysician 

personnel may serve as 

effective providers of 

nicotine dependence 

interventions

• Designate a nicotine dependence

treatment coordinator for every

clinical site

• Delineate the responsibilities of

the nicotine dependence treatment

coordinator (e.g., ensuring the

systematic identification of smokers,

ready access to evidence-based

cessation treatments [e.g., quitlines],

and scheduling follow-up visits)

• Communicate to each staff member

(e.g., nurse, physician, medical

assistant, pharmacist, or other

clinician) his or her role and

responsibility in the workflow and

delivery of nicotine dependence

services. Discuss these staff

responsibilities during training

of new staff

No PHS Guideline meta-analysis.

4. Promote hospital

policies that

support and provide

inpatient nicotine

dependence services

Provide nicotine 

dependence treatment 

to all tobacco users 

who are admitted to 

a hospital

• Implement a system to identify

and document the tobacco use

status of all hospital patients

• Identify a clinician(s) to deliver

nicotine dependence services to

inpatients at every hospital and

reimburse hospitals for delivering

such services

• Offer nicotine dependence

treatment to all hospital patients

who use tobacco

• Expand hospital formularies to

include FDA-approved nicotine

dependence medications

• Ensure compliance with The

Joint Commission’s regulations

mandating that all sections of the

hospital be entirely smokefree

and that patients receive cessation

treatments

• Educate hospital staff about

medications that may be used

to reduce nicotine withdrawal

symptoms, even if the patient is

not intending to quit at that time

• No PHS Guideline meta-analysis

• Rigotti and colleagues (2012), in

a Cochrane review of in-hospital

tobacco dependence treatment

programs, concluded that intensive

counseling interventions that

began during the hospital stay and

continued with supportive contacts

for at least 1 month after discharge

increased smoking cessation rates

after discharge (n = 25 studies):

OR = 1.37; 95% CI, 1.27–1.48

• Rigotti and colleagues (2012) also

concluded that adding nicotine

replacement therapy to an intensive

counseling intervention increased

rates of smoking cessation compared

with intensive counseling alone

(n = 6 studies): OR = 1.54; 95% CI,

1.34–1.79

Table 7.2 Continued
A Report of the Surgeon General

586 Chapter 7

and Affordable Care Act (ACA) and the approach for documenting tobacco use in EHRs in the Health Information 

Technology for Economic and Clinical Health Act

(HITECH) (Table 7.2).

As noted previously in this chapter, the Clinical 

Practice Guidelines were intended to help shape clinical 

practice, and thereby increase cessation—not just to serve 

as a repository of evidence on clinical policies. Numerous 

studies have addressed the impact of the Clinical Practice 

Guidelines on clinical performance and outcomes (Katz 

et  al. 2004, 2014; Lesho et  al. 2005; Smith et  al. 2005; 

Caplan et al. 2011; Institute of Medicine, Committee on 

Standards for Developing Trustworthy Clinical Practice 

Guidelines 2011; Moody-Thomas et al. 2011; Shelley et al. 

2011; Kruger et al. 2015). These studies have generally demonstrated that the implementation of guidelines (e.g., the 

Clinical Practice Guidelines or the “5  A’s” [Ask, Advise, 

Assess, Assist, Arrange] clinical intervention or its abbreviated version, the “AAR” [Ask, Advise, Refer])—via training, 

systems-level changes, or other actions—is associated 

with higher rates of delivery of guideline-recommended 

interventions for smoking cessation (see Chapter 6). Some 

studies have also demonstrated an association with higher 

rates of cessation and/or lower smoking prevalence. For 

example, Caplan and colleagues (2011) noted that training 

primary care physicians to deliver the 5 A’s was associated 

with significantly greater compliance with the interventions recommended in the Clinical Practice Guideline.

Data following the release of the guideline also revealed 

(a) a significant increase in the percentage of patients at 

U.S. Department of Veterans Affairs (VA) healthcare facilities who were counseled about smoking cigarettes and 

(b) a significant decrease in the percentage of VA patients 

who smoked cigarettes (Ward et al. 2003; Katz et al. 2004). 

Thus, the practices recommended in the Clinical Practice 

Guideline can enhance the provision of treatment for 

smoking and cessation-related outcomes.

Recommendations from the U.S. Preventive 

Services Task Force

Created in 1984, USPSTF is an independent, volunteer panel of national, nonfederal experts in prevention 

and evidence-based medicine who review relevant scientific evidence and make evidence-based recommendations 

about clinical preventive services, such as screenings, 

counseling services, and medications (USPSTF 2017).

In 2015, USPSTF conducted an evidence review and 

updated its recommendations regarding the clinical treatment of tobacco use in primary care practices (USPSTF 

2015). The USPSTF recommended that clinicians (a) ask 

Table 7.2 Continued

Strategy Action Strategies for implementation

Meta-analytic findings from the 

2008 Clinical Practice Guideline

5. Include nicotine 

dependence 

treatments (both 

counseling and 

medication), 

identified as 

effective in the 

Clinical Practice 

Guideline, as paid 

or covered services 

for all subscribers 

or members of 

health insurance 

packages

Provide all insurance 

subscribers—

including those 

covered by managed 

care organizations, 

workplace health plans, 

Medicaid, Medicare, 

and other government 

insurance programs—

with comprehensive 

coverage for effective 

nicotine dependence 

treatments, including 

counseling and FDAapproved medications

• Cover evidence-based nicotine 

dependence treatments (counseling 

and medications) as part of the 

basic benefits package for all 

health insurance packages

• Remove barriers to tobacco 

treatment benefits (e.g., copays, 

prior authorization)

• Educate all subscribers and 

clinicians about the availability 

of covered nicotine dependence 

treatments (both counseling 

and medications) and encourage 

patients to use these services

• Rates of intervention for persons 

who received tobacco use 

interventions as a covered health 

insurance benefit (vs. persons 

with no tobacco cessation health 

insurance benefit) (n = 3 studies): 

OR = 2.3; 95% CI, 1.8–2.9 

• Rates of quit attempts for persons 

who received tobacco use 

interventions as a covered health 

insurance benefit (vs. persons 

with no tobacco cessation health 

insurance benefit) (n = 3 studies): 

OR = 1.3; 95% CI, 1.0–1.5 

• Estimated abstinence rates for 

persons who received tobacco use 

interventions as a covered health 

insurance benefit (vs. persons 

with no tobacco cessation health 

insurance benefit) (n = 3 studies): 

OR = 1.6; 95% CI, 1.2–2.2

Source: Fiore and colleagues (2008).

Notes: CI = confidence interval; EHR = electronic health record; FDA = U.S. Food and Drug Administration; OR = odds ratio; 

PHS = U.S. Public Health Service.
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 587

Smoking Cessation

all nonpregnant adults about their tobacco use, advise 

them to stop using tobacco, and provide both behavioral 

interventions and FDA-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco; and (b) ask 

all pregnant women about their tobacco use, advise them 

to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. 

These recommendations are in the process of being 

updated. A draft research plan was posted on USPSTF’s 

website for public comment in early 2018 (USPSTF 2018).

Although the 2015 USPSTF recommendations focus 

primarily on clinical cessation interventions, they are 

included in this chapter because the USPSTF guidelines 

increasingly serve as the basis for making decisions about 

insurance coverage and assessing performance and quality 

measures. The USPSTF “A” rankings have federal regulatory and reimbursement implications (USPSTF 2015). 

For example, the 2010 ACA used USPSTF’s ratings as criteria for coverage requirements, requiring all non-grandfathered, private insurance plans to cover—without cost 

to the patient—preventive services that received “A” or 

“B” ratings (Patient Protection and Affordable Care Act 

of 2010), which included provision of tobacco cessation 

interventions to those who use tobacco (USPSTF 2009). 

As a result, a growing number of private insurers have 

included USPSTF “A” recommended preventive services 

as part of their basic package of covered health benefits; 

however, the administration and implementation of coverage for smoking cessation still varies widely across the 

insurance market, including among private insurers, state 

Medicaid programs, and Medicaid managed care plans 

(Kofman et al. 2012; American Lung Association 2015).

Overall, the evidence is sufficient to infer that the 

development and dissemination of evidence-based clinical 

practice guidelines increases the delivery of clinical interventions for smoking cessation.

Improving and Promoting Coverage 

of Treatment for Tobacco Use and 

Dependence

Treatments for tobacco use and dependence can be 

covered through (1) health insurance, which includes 

coverage through private insurance (both the individual 

market and the employer markets), Medicaid, or Medicare, 

or coverage provided to active-duty military and veterans; and/or (2) employer-based wellness programs that 

may be offered in conjunction with health insurance. 

Comprehensive coverage of tobacco cessation treatments 

includes coverage of evidence-based cessation treatments (individual, group, and telephone counseling) and 

FDA-approved cessation medications (Fiore et al. 2008). 

Comprehensive coverage removes or minimizes barriers, 

such as cost-sharing and prior authorization, that can 

impede access to cessation treatments (CDC 2014a, 2015; 

McAfee et al. 2015; Singleterry et al. 2015). As an example, 

effective 2011, the U.S. Office of Personnel Management 

(OPM) implemented model comprehensive insurance coverage of evidence-based cessation interventions for federal employees (OPM 2010a,b,n.d.). The insurance covers 

individual, group, and telephone counseling and all seven 

FDA-approved cessation medications for at least two quit 

attempts per year with no copays, coinsurance, or deductibles and no annual or lifetime limits (OPM 2010a,b,n.d.; 

CDC 2014b). Despite the model coverage approach, one 

potential limitation of this benefit is that some federal prescription plans require a health risk assessment as a precondition to getting medications covered at 100%; otherwise, there are copays for medications. Additionally, these 

assessments are primarily completed online, which could 

diminish utilization, particularly by persons with limited 

or no access to the Internet (CDC 2014a). Another barrier is that many plans require a prescription for cessation medications, even if they can be purchased over the 

counter, so persons can be reimbursed.

In spring 2019, OPM included language in its annual 

call letter and technical guidance for Federal Employees 

Health Benefits (FEHB) program carriers that reaffirmed 

and updated the comprehensive tobacco cessation coverage benefit, which was originally introduced in 2011, 

for federal employees (OPM 2019b). This new language 

highlights

• The effectiveness of combination nicotine replacement therapy (NRT),

• The fact that the combination of counseling and medication gives smokers the best chance of quitting,

• The importance of making cessation coverage barrier 

free and of promoting this coverage so that members 

and providers are aware of it and use it, and 

• Opportunities to partner with pharmacists to provide education and decision support on cessation 

medications.

The call letter (OPM 2019b) and technical guidance 

(OPM 2019a) also call for FEHB plans to educate parents and 

healthcare providers on approaches to help prevent youth 

from using all tobacco products, including e-cigarettes, and 

on approaches to help youth who already use tobacco products to quit. Beyond its direct impact on 8.2 million federal 

employees, family members, retirees, and annuitants, this 
A Report of the Surgeon General

588 Chapter 7

updated cessation coverage from OPM has the potential to 

provide a model for private health insurers and employers, 

and it creates an opportunity to promote the updated cessation coverage to federal employees.

Health insurance coverage for evidence-based treatment of tobacco use and dependence complements the 

efforts of health systems and healthcare providers by 

making it easier for them to connect patients with treatment (Fiore et al. 2008; CDC 2014a; McAfee et al. 2015). 

Regardless of how well designed a coverage benefit may 

be, coverage alone, without promotion, is insufficient. It 

is critical that benefits for smoking cessation, whether 

offered through a health insurer or an employee wellness 

program, be promoted to increase awareness and use of 

covered treatments. The next section outlines the scientific evidence base for the coverage and promotion of benefits that address smoking cessation.

Health Insurance Coverage

The availability of comprehensive health insurance 

coverage for evidence-based treatment of tobacco use and 

dependence has been associated with higher utilization of 

cessation treatment and with successful cessation. In an 

examination of four insurance plans (N = 90,005 enrollees), 

Curry and colleagues (1998) showed that the highest 

rates of cessation were achieved for the group of smokers 

that had no barriers to benefits (i.e.,  no cost for behavioral counseling and NRT). The study concluded that full 

insurance coverage, compared with coverage with copays, 

was associated with a doubling of the overall quit rate in 

this population. Later, the Clinical Practice Guideline

(Fiore et al. 2008) reported that providing tobacco cessation treatments as a covered health insurance benefit was 

associated with a greater likelihood that smokers would 

make a quit attempt (OR = 1.3; 95% CI, 1.0–1.5); a greater 

likelihood that persons who smoke would receive treatments for tobacco use and dependence during a healthcare 

visit (OR = 2.3; 95% CI, 1.8–2.9); and greater odds that 

they would quit successfully (OR = 1.6; 95% CI, 1.2–2.2) 

(Table 7.2) (Alesci et al. 2004; Holtrop et al. 2005; Murphy 

et al. 2005). Using nationally representative data, another 

study reported that Medicaid enrollees in states with 

more comprehensive coverage of cessation treatment had 

higher-than-predicted successful quit rates (8.3%) compared with those living in states with more limited coverage (ranging from 4.0% for pharmacotherapy without 

copayment to 5.6% for pharmacotherapy with copayment) 

(Greene et  al. 2014). In another study using nationally 

representative data, Kostova and colleagues (2018) found 

that state Medicaid coverage of both cessation counseling 

and cessation medication was associated with an estimated 

mean increase of 3.0 percentage points (p <.10) in past-year 

quitting among covered Medicaid beneficiaries compared 

with persons without coverage. In addition, Ku and colleagues (2016) found that among Medicaid enrollees, state 

Medicaid coverage of at least one form of NRT, bupropion, 

and varenicline was associated with a 24–34% increase in 

the use of cessation medications.

Uniform implementation of comprehensive, evidencebased cessation coverage across health insurance products 

with minimal barriers (e.g., no prior authorizations) may 

also increase clinicians’ delivery of cessation interventions 

by making it easier for them to understand their patients’ 

coverage and increasing their confidence that their patients 

will be able to access the treatments they recommend 

(Kofman et al. 2012; McAfee et al. 2015; van den Brand 

et al. 2017).

Insurance coverage of tobacco cessation can also 

be a cost-effective benefit. For example, in 2006, the 

Massachusetts Medicaid program (MassHealth) began 

offering and intensely promoting comprehensive coverage 

for tobacco cessation with minimal barriers to all Medicaid 

enrollees. During the first 3 years of the program, more 

than 75,000 MassHealth members who smoked cigarettes 

(nearly 40% of MassHealth smokers) had used covered 

cessation treatments, with far more using cessation medications than counseling (Land et al. 2010a,b; CDC n.d.). 

Use of the benefit substantially influenced cessation, as 

the rate of cigarette smoking among MassHealth members 

decreased from 38.3% to 28.3% over 2-1/2 years (Land 

et al. 2010b). In another Massachusetts-based study, Land 

and colleagues (2010a) found that coverage for smoking 

cessation was associated with substantial decreases in hospitalization rates for cardiovascular disease, with annualized declines of 46% and 49% in admissions for acute 

myocardial infarction and other acute coronary heart disease diagnoses, respectively, among Medicaid smokers 

who used the benefit. An economic analysis focusing on 

the costs and savings from the perspective of the Medicaid 

program indicated that every $1.00 spent on medications, 

counseling, and promotional outreach was associated 

with a reduction of $3.12 in cardiovascular-related hospitalization expenditures, resulting in net savings between 

$2.00 and $2.25 (Richard et al. 2012).

Despite this evidence, numerous insurers have 

offered several reasons why they believe coverage should 

not be required, including

• Lack of evidence for effectiveness of interventions;

• Lack of evidence that coverage increases utilization;

• Coverage could decrease participant motivation 

by removing personal financial commitment to 

the cessation treatment program, thus potentially 

decreasing the odds of success;
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 589

Smoking Cessation

• Lack of interest from smokers and institutional

purchasers;

• The perception that smoking is a societal problem,

rather than a healthcare problem;

• Concern that provision of coverage could make

insurance unaffordable; and

• Concern that some of the health benefits of smoking

cessation take years to be fully realized (e.g., reducing 

the risk of lung cancer or chronic obstructive pulmonary disease), and therefore this benefit may

not accrue to the insurer, since the smoker may no

longer be in the health plan when the benefit is realized (Gollust et al. 2008).

Over time, many of these rationales have been systematically refuted, often through large-scale research trials 

(Curry et al. 1998; Joyce et al. 2008; Hamlett-Berry et al. 

2009; Smith et al. 2010; Fu et al. 2014, 2016). Nonetheless, 

adoption of smoking cessation coverage remains limited 

and varies widely (Kofman et al. 2012). Coverage mandates 

at the state and national levels can provide an important 

lever to encourage the delivery and use of evidence-based 

treatments and clinical services for smoking cessation and 

to standardize a minimum level of coverage. Such mandates often have components that are designed to influence the behaviors of both the beneficiary and the clinician 

or health system.

Examples of current insurance coverage in the United 

States and considerations for coverage across the major 

health insurance categories are outlined below, including 

for private insurance, Medicaid, Medicare, and Military 

Health System and Veteran’s Health Administration. 

Specific epidemiologic data on the prevalence of quit 

attempts, use of cessation treatments, and recent cessation 

success is not covered in this chapter but can be found in 

Chapter 2.

Private Insurance

In 2017, 67% of insured U.S. adults were covered 

through the private market, 56% were insured through 

their employers, and 16% were insured through nongroup 

plans or health insurance exchanges; these figures do not 

total 100% because persons may have had more than one 

type of coverage during the calendar year (Berchick et al. 

2018). The 2010 ACA included components designed to 

increase rates of tobacco cessation among members of private, non-grandfathered health plans via improved coverage 

for cessation treatments (Kofman et al. 2012; McAfee et al. 

2015). Further subregulatory guidance (U.S. Department 

of Labor 2014; McAfee et al. 2015) clarified that insurers 

should provide a minimum of two courses of evidencebased treatment for tobacco cessation per year that include 

both cessation counseling and cessation medication with 

no cost sharing or prior authorization (Table 7.3).

The limited evidence available suggests that much 

private insurance coverage continues to fall short of this 

standard. Bloom and colleagues (2018) reported that some 

insurance plans may not recognize certain types of clinicians as providers of tobacco counseling for reimbursement purposes. In addition, some plans may explicitly 

exclude intensive preventive counseling or may charge 

high copays for longer, more intensive counseling visits. 

This may be because of a reliance on the 2009 USPSTF 

tobacco cessation recommendations, which did not clearly 

define intensive treatment, instead of a reliance on the 

more detailed 2014 subregulatory guidance from the U.S. 

Department of Labor (2014). However, the 2015 tobacco 

cessation recommendations from USPSTF clarified that 

Table 7.3 Affordable Care Act guidance of coverage of tobacco cessation treatmenta

“A group health plan or health insurance issuer will be considered in compliance with the ACA’s requirement to cover tobacco-use 

counseling and interventions if, for example, it covers the following, without cost sharing or prior authorization:

•

• 

Screening of all patients for tobacco use; and

For enrollees who use tobacco products, at least two tobacco cessation attempts per year, with coverage of each quit

attempt including:

 – Four tobacco-cessation counseling sessions, each at least 10 minutes long (including telephone, group, and individual 

counseling); and

All FDA-approved tobacco-cessation medications (including prescription and over-the-counter) for a 90-day treatment 

regimen when prescribed by a health care provider”

Source: McAfee and colleagues (2015, p. 6) and U.S. Department of Labor (2014).

Notes: ACA = Patient Protection and Affordable Care Act; FDA = U.S. Food and Drug Administration. aFDA has approved seven smoking cessation medications: five nicotine medications (patch, gum, lozenge, nasal spray, and inhaler) and 

two non-nicotine pills (bupropion and varenicline). Information is adapted from U.S. Department of Labor (2014); additional information 

is available at American Lung Association (n.d.a).
A Report of the Surgeon General

590 Chapter 7

intensive visits should last at least 20 minutes, multiple 

sessions should be provided (at least four in-person counseling visits), and cessation rates may plateau after 90 minutes of total counseling contact time (USPSTF 2015).

Public Health England (2017) outlined an example 

of a model benefit that offers intensive counseling (i.e., 

individual and group counseling with more frequent and 

longer visits than outlined in the subregulatory guidance in the United States) and robust medication benefits 

(e.g., combination short- and long-acting NRT) for every 

smoker in the country. Table 7.4 includes some examples 

of cessation benefit models. These models have strengths 

and weaknesses, with MassHealth and Public Health 

England having the most comprehensive and intensive 

models. As noted in Chapter 6, it is important for insurers 

to adequately and fairly reimburse or “incentivize” healthcare systems and clinicians at a macro level for the costs of 

providing cessation counseling (Nolan and Warner 2017). 

Increasing clinician reimbursement for cessation counseling time (including high-intensity counseling) could 

help to increase reach and quit rates.

Medicaid

Medicaid is a joint federal and state program that 

provides health coverage for some individuals and families with low-incomes, qualified pregnant women and 

children, senior citizens, and people with disabilities 

(Medicaid.gov n.d.). Given that Medicaid enrollees comprise a low-income, disadvantaged population with disproportionately high rates of cigarette smoking (CDC 2014a, 

2015; Jamal et al. 2016), and that smoking-related disease 

is a major driver of Medicaid costs (Xu et al. 2015b), comprehensive Medicaid coverage for tobacco use and dependence treatment is especially important. In 2016, almost 

20% of insured U.S. adults were covered through Medicaid 

(Kaiser Family Foundation n.d.b). Smokers who are 

enrolled in Medicaid are more likely than privately insured 

and uninsured smokers to have chronic diseases and to 

experience severe psychological distress (Zhu et al. 2017). 

In 2017, 24.5% of adult Medicaid enrollees were current 

cigarette smokers, compared with 10.5% of adults with 

private health insurance (Wang et  al. 2018) amounting 

to nearly 7.2  million Medicaid recipients, who make up 

about 21% of all U.S. adult smokers (NHIS, 2017 data). As 

discussed in Chapter 6, the smoking rate among Medicaid 

enrollees remained unchanged from 1998 to 2013 (Zhu 

et al. 2017). During 2006–2010, smoking-related diseases 

accounted for about 15% (or more than $39  billion) of 

annual Medicaid spending (Xu et al. 2015b).

National health objectives include a target for all 

state Medicaid programs to adopt comprehensive coverage 

of treatments for smoking cessation, including coverage of 

individual, group, and telephone cessation counseling and 

all seven FDA-approved cessation medications (DiGiulio 

et al. 2018). Although Medicaid cessation coverage varies 

by state, it has been gradually improving in recent years, 

especially with regard to cessation medications (DiGiulio 

et al. 2016, 2018). Changes in Medicaid policies have contributed, in part, to improved cessation coverage. For 

example, the Section 4107 of the 2010 ACA requires traditional (non-expansion) state Medicaid programs to cover 

cessation counseling and FDA-approved cessation medications for pregnant women with no cost-sharing (effective October 2010), and Section  2502 of the 2010 ACA 

prohibits these programs from excluding cessation medications from coverage for all traditional adult Medicaid 

enrollees (effective January 2014) (McAfee et al. 2015). In 

addition, in 2011, the Centers for Medicare & Medicaid 

Services (CMS) provided guidance that tobacco quitlines 

qualified as an allowable Medicaid administrative activity. 

As a result, state Medicaid programs became eligible to 

receive a 50% administrative match for quitline services 

provided to Medicaid beneficiaries (CMS 2011). While this 

policy does not impact state Medicaid cessation coverage 

per se, it provides Medicaid enrollees with increased access 

to evidence-based forms of cessation counseling.

Currently, all states (including the District of 

Columbia) cover at least some proven cessation treatments 

for all Medicaid enrollees; about three-fifths of states cover 

individual cessation counseling, and only about one-fifth 

of states cover group counseling; and about three-fifths of 

states cover all seven FDA-approved cessation medications 

(DiGiulio et al. 2018). Almost all states impose coverage 

barriers which restrict access to covered cessation treatments, especially cessation medications; common barriers 

include prior authorization, limits on duration, annual 

limits on quit attempts, and copayments.

Medicare

Medicare is a health insurance program for people 

aged 65 or older, people under age 65 with certain disabilities, and people of all ages with permanent kidney failure 

requiring dialysis or a kidney transplant (CMS 2019). 

In 2016, about 15% of insured U.S. adults received coverage through Medicare (Kaiser Family Foundation n.d.b). 

Medicare coverage of tobacco cessation affects a smaller 

number of beneficiaries compared with Medicaid, but it is 

still important, particularly because tobacco-related diseases often first become evident or worsen among older 

smokers, and cessation at any age is beneficial to health 

(USDHHS 2010). In recent years, Medicare has taken steps 

to improve coverage for cessation. For example, Medicare 

now covers—without cost sharing—multisession, individual counseling for two quit attempts per year (eight 

total visits). However, Medicare does not cover group 

or telephone counseling (Medicare Interactive n.d.). 
Table 7.4 Models of comprehensive tobacco cessation coverage and health insurance benefits

Benefit plan Counseling visits Counseling format Counseling dose/time Setting Clinician type Medications

Mass Medicaid 

(Massachusetts 

Department of Public 

Health 2014)

Up to 16 face-to-face 

visits per year; more 

visits with prior 

authorizationa

At least two 45-minute 

intake visits; 14 individual 

or group visits

Individual >30 minutes; 

group >60 minutes

Massachusetts Physicians or nurses, 

certified tobacco 

treatment specialists, etc.

Seven FDA-approved 

medications, 180 days 

each, combinations

U.S. Office of Personnel 

Management (n.d.)

At least 8 visits per year Individual, group, and 

telephone

>30 minutes for individual 

visits

Federal employee 

health benefit

Not specified Seven FDA-approved 

medications,b 180 days 

each, combinations

Patient Protection and 

Affordable Care Act, 

U.S. Department of 

Labor (2014)

At least 8 visits per year Individual, group, 

and telephone

>10 minutes for 

each visit

Applicable to group 

health plans and U.S. 

private health insurance

Not specified Seven FDA-approved 

medications, 180 days 

each, combinations

Grade A Recommendation 

(U.S. Preventive Services 

Task Force 2015)

Multiple sessions, dose 

response, more or 

longer sessions improve 

cessation rates; >4 inperson visits per year; 

>8 visits largest effect 

(quit rate)

Individual, group, 

and telephone

Intensive in-person 

counseling for 

>20 minutes per visitc; 

minimal or brief visits also 

covered

Applicable to U.S. 

health insurance plans; 

best and most effective 

combinations are those 

that are acceptable and 

feasible to the patient

Specialized cessation 

counselors, psychologists, 

social workers, physicians, 

nurses, etc.

Seven FDA-approved 

medications, 

combinations

Public Health England 

(2017)

6–12 groupdvisits, 

6–12 individuald visits, and 

6–12 telephone visits

Group, individual, 

telephone with 

pharmacotherapy, brief 

physician or pharmacist 

with pharmacotherapy

Approximately 

60 minutes per 

group, 30–45 minutes per 

person, and 

15–30 minutes 

for telephone

England National Health 

Service primary care, and 

Stop Smoking Specialist 

clinics

Seven medications and 

combination medications

Veterans and Military, 

U.S. Department of Defense 

(Huang 

et al. 2018)

Not specified Individual, group, 

telephone, and brief 

primary care

Brief primary care; 

intensive counseling time 

not specified

U.S. Department of 

Defense; Veterans 

Affairs health system

Not specified Seven FDA-approved 

medications, combinations

Notes: FDA = U.S. Food and Drug Administration.

aIn Massachusetts, the telephone quitline is independent of face-to-face treatment, and Mass Medicaid patients can access unlimited phone counseling via the quitline.

bFor smokers to receive quitting medications covered at 100%, some federal plans require them to complete an online health risk assessment as a precondition. Otherwise, smokers have 

copayments. 

cSixteen of 38 studies reported more than 300 total minutes of counseling. For studies examining combinations of behavioral and pharmacotherapy interventions, the intensity of behavioral 

counseling was more than 300 minutes in 60% of the studies.

dBreath carbon monoxide testing—a validated biomedical outcome measure—occurs at each intensive individual or group visit with a tobacco treatment specialist, which assists with 

treatment planning and motivation. Clinicians are trained to the standards of the National Centre for Smoking Cessation and Training and receive continued supervision.

Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 591

Tobacco treatment 

specialists,dprimary 

care physicians, and 

pharmacists
A Report of the Surgeon General

592 Chapter 7

Medicare Part D covers prescription cessation medications 

but not over-the-counter cessation medications (Medicare 

Interactive n.d.); the covered prescription medications are 

subject to copays.

Military Health Systems and Veteran’s 

Health Administration

Veterans and active-duty military personnel smoke 

cigarettes at higher rates than the general U.S. adult population (Bray et al. 2009), making coverage of smoking 

cessation through health plans from VA and the U.S. 

Department of Defense (DoD) important. Tobacco use 

can affect military readiness and is costly to the healthcare systems of the DoD and VA. A DoD (2013) survey 

estimated that nearly half of all military service members 

(49.2%) had used a tobacco product (cigarettes, smokeless 

tobacco, cigars, pipes, or e-cigarettes) during the previous 

12 months. Moreover, an estimated 171,000 persons who 

were active-duty service members in 2014 are projected 

to die in the coming decades because of tobacco-related 

disease (Roulo 2014). DoD spends more than $1.6 billion 

annually on tobacco-related health expenses (Institute 

of Medicine 2009). Tobacco cessation coverage through 

DoD’s Military Health System or Defense Health Agency 

is complicated due to varying health policies across the 

services. Coverage across all services generally includes 

cessation counseling, a dedicated telephone quitline that 

serves the military, online support, and access to over-thecounter and prescription cessation medications.

In 2016, VA provided healthcare for approximately 

1.3  million enrollees (14.9% of its total enrollment) 

who currently smoked cigarettes (Huang et  al. 2017). 

Enrollees have access to several evidence-based benefits, 

including screening for tobacco use, brief counseling 

in primary care settings and more intensive counseling 

through clinics that specialize in treating tobacco use, all 

FDA-approved cessation medications, a dedicated national 

quitline (1-855-QUIT-VET) that serves veterans who are 

enrolled in the VA Health Care system, and a mobile texting program (SmokeFreeVET) (Huang et al. 2017). Once 

found eligible, veterans can receive all their health services from a VA facility or a VA networked facility, which 

can further help to enhance the provision of and continuity in care to this population.

Removing Barriers to Access

Insurance coverage and benefits can be designed in 

ways that encourage persons to seek out specific types of 

care or specific types of clinicians to provide such care. For 

example, removing barriers to access (e.g.,  copays, coverage limits, prior authorization) encourages individuals to 

use covered cessation treatments (Curry et al. 1998; Fiore 

et al. 2008; Land et al. 2010b; Greene et al. 2014; Friedman 

et  al. 2016; van den Brand et  al. 2017). The manner in 

which care is structured and reimbursed in clinical settings 

can also improve access to tobacco use and dependence 

treatment. Several incentive programs and quality measures have been put in place at the federal level to remove 

barriers and improve access to care. However, because 

many of these initiatives have been implemented in only 

the past 5–10 years, limited evidence exists on the effects 

they can have on cessation, particularly at a national level. 

Furthermore, evidence is unclear on the extent to which 

recent policy changes have been successful at removing 

these barriers. Table 7.5 lists each of these policy initiatives, 

their enactment date, and the specific provisions designed 

to encourage cessation through increased access to care 

or removal of barriers. Although specific studies on these 

recent policy initiatives have not been conducted, studies 

generally suggest that removing barriers to access increases 

the use of evidence-based cessation treatments and rates of 

quitting (Curry et al. 1998; Fiore et al. 2008; Land et al. 

2010b; Greene et al. 2014; van den Brand et al. 2017).

Health insurance premium differentials, which 

allow insurers to charge higher premiums for tobacco 

users, could be another barrier to accessing cessation 

coverage and treatment. Tobacco use is one of only four 

factors that can be considered in setting health insurance premiums under the ACA (Patient Protection and 

Affordable Care Act of 2010); the other factors are individual (vs. family) coverage, rating area, and age (Curtis 

and Neuschler 2012; American Lung Association n.d.b). 

Although charging persons who use tobacco more for 

health insurance could motivate them to quit, such 

charges could also cause persons to avoid obtaining health 

insurance or to conceal their smoking status to avoid the 

additional charges, which would make it harder to identify smokers and engage them in cessation treatment 

(Kaplan et al. 2014). Based in part on these potential concerns, as of October 16, 2019, four states and the District 

of Columbia have barred insurers in both the individual 

and small group markets from charging smokers more for 

insurance premiums (Kaiser Family Foundation n.d.a). 

Because premium differentials based on tobacco use status 

are a recent phenomenon, only limited data are available 

on their effect on tobacco use and cessation and on ways 

to design differentials that can minimize their potential 

negative impacts and promote tobacco cessation.

Friedman and colleagues (2016) used data from the 

2011–2014 Behavioral Risk Factor Surveillance System 

to examine the effects of surcharges for tobacco use on 

insurance status and smoking cessation among adults who 

were the most likely to purchase insurance from health 

insurance exchanges. The study found that, compared 

with smokers who faced no surcharges, smokers facing 
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 593

Smoking Cessation

Table 7.5 Healthcare system approaches designed to encourage smoking cessation

Organization Date enacted Provision

Quality Payment Program (n.d.b), part of the Medicare 

Access and Children’s Health Insurance Program 

Reauthorization Act, provides incentives to providers 

and health systems to deliver quality, evidence-based 

clinical care to treat Medicare patients.

2017 Requires the screening of all patients, 18 years of age 

and older, for tobacco use at least once within 24 months 

AND the provision of a tobacco cessation intervention 

if the patient is identified as a tobacco user

Comprehensive Primary Care is a collaboration between 

CMS and private and public payers that aims to improve 

the delivery of primary care and achieve better care, 

smarter spending, and healthier people (CMS 2017c).

2012 Requires the screening of all patients, 18 years of age 

and older, for tobacco use at least once within 24 months 

AND the provision of a tobacco cessation intervention 

if the patient is identified as a tobacco user

Accountable Care Organizations are groups of doctors, 

hospitals, and other healthcare providers that come 

together to give coordinated, high-quality care to 

patients. The goal of coordinated care is to ensure that 

patients, especially the chronically ill, get the right care 

at the right time, while avoiding unnecessary duplication 

of services and preventing medical errors (CMS 2017a).

2010 Identifies and treats all patients who use tobacco

National Quality Forum (n.d.b) is a nonprofit, 

nonpartisan, public service organization that reviews, 

endorses, and recommends the use of standardized 

healthcare performance measures that are frequently 

used to assess performance in outpatient settings.

2009 Endorses a measure that screens all patients 18 years 

of age and older for tobacco use at least once within 

24 months AND the provision of a tobacco cessation 

intervention if the patient is identified as a tobacco 

user. This performance measure is used in numerous 

programs that measure the quality of performance, 

including Meaningful Use, Medicare Shared Savings 

Program, CMS’s Accountable Care Organization 

Program, and Physician Quality Reporting System.

Patient-Centered Medical Home is a care delivery model 

in which primary care physicians are responsible for 

coordinating necessary care for their patients (CMS n.d.).

2006 Recommends the use of registries, including a tobacco 

registry, to drive patient care, including the tracking 

of patient tobacco use and quit attempts

National Committee for Quality Assurance (n.d.a,b) 

is a private, not-for-profit organization dedicated to 

improving healthcare quality and developing quality 

standards and performance measures for a broad range 

of healthcare entities.

2000 Measures performance on medical assistance with 

smoking and tobacco use cessation, including advising 

smokers and tobacco users to quit, discussing cessation 

medications, and discussing cessation strategies

Inpatient Prospective Payment System is the Medicare 

payment program for hospitals tied to performance 

measurement of:

• Acute care hospitals PPS (CMS 2017b) and

• Inpatient psychiatric facilities (CMS 2017d).

1983 Uses The Joint Commission’s Tobacco Inpatient 

Measures 1 (in 2015) and 2 and 3 (in 2016) for 

the prospective payment system for inpatient 

psychiatric facilities

Notes: CMS = Centers for Medicare & Medicaid Services.

medium or high surcharges had significantly reduced 

insurance coverage (reductions of 4.3 percentage points 

and 11.6 percentage points, respectively) and no significant change in smoking cessation. However, compared 

with smokers with no surcharges, smokers facing low 

(but non-zero) surcharges were significantly less likely 

to quit smoking, and smokers in groups with high surcharges were more likely to quit smoking. In addition to 

these data suggesting reduced insurance among smokers 

who are charged surcharges, premium differentials could 

also cause financial hardship for tobacco users by substantially increasing the cost of health insurance coverage (see 

Chapter 6). To decrease the potential negative impact of 

this barrier on smokers, insurers could offer policyholders 

access to a comprehensive smoking cessation benefit program, promote the program to increase awareness and 

use, and waive the differential for those who are making 

an assisted quit attempt. As of 2017, insurers in the 

small-group market were required to waive the differential for tobacco users who are participating in a cessation 
A Report of the Surgeon General

594 Chapter 7

program, but this requirement does not apply to the individual market (CMS 2013).

Another approach to decreasing barriers is widespread implementation of cessation programs at worksites 

(Cahill and Lancaster 2014), which can increase employees’ 

access to high-quality treatment, boost employee morale, 

and give tools to smokers that help them successfully quit 

(Castellan et al. 2015). Employers and governments are two 

major purchasers of health insurance, so employers are 

also a key driver of health insurance coverage. Employers 

have an even greater economic incentive than insurers 

to help smokers quit because they stand to benefit from 

increased worker productivity and reduced healthcare 

costs; in particular, large self-insured employers have an 

especially strong incentive to reduce employee smoking 

rates because they often bear the risk for smoking-related 

disease costs (Bunn et al. 2006; Gollust et al. 2008; Berman 

et al. 2014; Xu et al. 2015b). Large employers are also wellpositioned to insist that insurers include cessation coverage in standard insurance policies, rather than limiting 

this coverage to riders.

Promoting Coverage for Utilization of Smoking 

Cessation Treatments and Benefits

Coverage of proven cessation treatments by insurers 

and employers is a necessary but not sufficient condition 

for increasing smokers’ use of these treatments and their 

cessation rates. For such coverage to have an impact, it 

must be systematically promoted to smokers and healthcare providers to ensure that both groups are aware of 

the coverage and use the covered treatments (Land et al. 

2010b; CDC 2014a, 2015; McAfee et al. 2015). Promotion 

of coverage benefits is vital to increase use of these 

interventions, which in turn helps more smokers quit 

(McMenamin et  al. 2004, 2006; Keller et al. 2011). For 

example, in the MassHealth example discussed previously, 

widespread promotion of the benefit to members and 

providers was viewed as central to the program’s success 

(Land et al. 2010b). Similarly, the state Medicaid program 

in Wisconsin conducted a promotional campaign that 

targeted both Medicaid-certified providers and Medicaid 

enrollees. That campaign led to increases in the use of 

cessation medications and in the number of Medicaid 

members enrolling in the Wisconsin Tobacco Quit Line 

(Keller et  al. 2011). Finally, following an increase in 

Minnesota’s tobacco tax, ClearWay Minnesota conducted 

a 6-week media campaign to promote its quitline services 

(QUITPLAN). This campaign resulted in a 160% increase 

in calls and web visits combined and an 81% increase in 

enrollment for QUITPLAN services (Keller et al. 2015). For 

greatest impact, promotions should target both tobacco 

users and their healthcare providers, as was done in 

Massachusetts and Wisconsin. Ideally, states should track 

utilization of the covered treatments to gauge the effectiveness of the coverage and to encourage improvements 

in the promotional efforts (Land et al. 2010b; CDC 2014a; 

McAfee et al. 2015; Singleterry et al. 2015).

Taken together, the evidence is sufficient to infer that 

with adequate promotion, comprehensive, barrier-free, 

evidence-based cessation insurance coverage increases 

the availability and utilization of treatment services for 

smoking cessation.

Quality and Performance Measures 

and Payment Reforms

In general, performance measures can motivate 

quality improvements and create accountability for decisions and behaviors (Smith et al. 2008). Tobacco-related 

quality measures are tools that can be used to evaluate how 

well healthcare providers, practices, and systems are doing 

on the delivery of tobacco use and dependence treatment. 

Quality measures also exist for health plans. The most widely 

used tobacco-related quality measures are endorsed by the 

National Quality Forum (NQF)—a nonprofit, nonpartisan, 

public service organization that reviews, endorses, and 

recommends the use of standardized measures of healthcare performance (Kizer 2000). For example, NQF Number 

0028 is one of the most widely used measures for tobacco 

use screening and cessation (NQF n.d.a). It measures the 

percentage of patients 18 years of age and older who are 

screened for tobacco use at least once during a 2-year 

measurement period and, among those who are tobacco 

users, the percentage who have received an intervention 

(brief counseling [3  minutes or less]) and/or pharmacotherapy). Currently, this measure is used in several performance and quality measurement programs, including 

Medicare and Medicaid Electronic Health Record Incentive 

Programs (commonly referred to as “Meaningful Use”2); 

the Medicare Shared Savings Program; CMS’ Accountable 

Care Organization Program; CMS’ Merit-based Incentive 

Payment System and Medicare Access and Children’s 

Health Insurance Program (or CHIP) Reauthorization 

Act of 2015; and the Physician Quality Reporting System. 

Although NQF Number 0028 includes both screening for 

2Meaningful Use is defined as the use of certified EHR technology to improve the quality, safety, and efficiency of healthcare and reduce 

health disparities; engage patients and families; improve the coordination of care for both population and public health; and maintain 

the privacy and security of patient health information.
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 595

Smoking Cessation

tobacco use and receipt of a counseling intervention, it 

does not include or require referral to other, more intensive interventions with follow-up (e.g., quitlines, specific 

behavioral counseling, or coaching).

Linking Quality Measures to Payment

Quality measures can influence the frequency and 

consistency with which specific interventions are delivered. This effect may be strengthened when quality measurement is linked to payment. Payment-based strategies include (a) performance-based measures that provide 

financial incentives (or penalties) if a clinician or health 

system provides (or neglects to provide) the targeted clinical intervention and (b) innovative payment and delivery 

models that link payment to the outcomes of care rather 

than the quantity of care provided (i.e.,  value-based as 

opposed to volume-based healthcare payment models). 

The Quality Payment Program (n.d.a) provides a tangible 

example of this. Substantial scientific evidence shows that 

“pay-for-performance” programs that target clinicians, 

clinics, and health systems are associated with higher 

rates of delivery of clinical interventions for tobacco use 

and dependence than programs that do not offer an incentive (Kruse et al. 2013). However, the evidence is mixed as 

to whether such programs are associated with increases in 

quit rates (Roski et al. 2003; Millett et al. 2007; Twardella 

and Brenner 2007; An et al. 2008; Hung and Green 2012; 

Hamilton et al. 2013; Kruse et al. 2013; McLeod et al. 2015). 

For example, in a systematic review, Hamilton and colleagues (2013) identified 18 studies (including 3 randomized studies and 15 observational studies) that explored the 

effects of pay-for-performance programs on smoking cessation. The review found that financial incentives appeared 

to increase the recording of smoking status and the provision of advice to quit and referral to cessation services, but 

results for quit rates and long-term abstinence were mixed 

in the five studies that reported these outcomes.

Overall, the evidence is sufficient to infer that strategies that link smoking cessation-related quality measures to payments to clinicians, clinics, or health systems 

increase the rate of delivery of clinical treatments for 

smoking cessation.

Health Plan-Based Quality Measures

The National Committee for Quality Assurance 

(NCQA) works with health plans and others to improve 

the quality of healthcare. To be accredited by NCQA, 

health plans must report data for more than 40 performance standards. Health plans in every state, the District 

of Columbia, and Puerto Rico are NCQA accredited, and 

recent data indicate that those plans cover 109  million Americans, or 70.5% of all Americans enrolled in 

health plans (NCQA n.d.a). The Healthcare Effectiveness 

Data and Information Set (HEDIS) is an NCQA program 

that measures health plan performance and patient satisfaction; more than 90% of America’s health plans use 

HEDIS. With regard to performance on tobacco use and 

dependence treatment, HEDIS measures the provision of 

tobacco cessation advice offered to tobacco users and discussions about cessation medications and other tobacco 

use and dependence treatment strategies (NCQA n.d.c). 

Because so many plans collect HEDIS data and the measures are so specifically defined and collected over time, 

the use of HEDIS makes it possible to compare performance across health plans.

Hospital-Based Performance Measures

The Joint Commission is an independent, nonprofit 

organization that accredits more than 21,000 healthcare 

organizations and programs in the United States (The 

Joint Commission n.d.). Typically, payment by insurers, 

including CMS and other federal payers, is contingent 

upon successful accreditation by a certifying organization, such as The Joint Commission. One criterion in 

the accreditation process for hospitals is to successfully 

meet selected performance measures. For certification by 

The Joint Commission, hospitals must select and report 

on 6  of 14  performance domains; 1  of these domains is 

tobacco cessation.

In 2012, The Joint Commission released an updated 

set of performance measures on tobacco cessation for 

hospitals (Fiore et al. 2012). To meet these performance 

measures, hospitals must (1)  identify and document 

tobacco use status for all hospital patients 18 years of age 

and older, (2) demonstrate that evidence-based cessation 

counseling and medication are provided or offered to identified tobacco users during hospitalization, and (3) demonstrate that evidence-based cessation counseling and 

medication are provided or offered to identified tobacco 

users at discharge. Within certain constraints, hospitals 

may choose which performance measures they report. 

As of September 2018, only about 5% of accredited acute 

care hospitals in the United States (170 of 3,328 reporting 

hospitals, including 13  VA and 11  DoD hospitals) had 

selected the tobacco use identification and treatment 

delivery measures and were reporting relevant data to The 

Joint Commission (personal correspondence with The 

Joint Commission, March 18, 2019). This is likely because 

these performance measures (a) are voluntary and certain 

other measures are required or tied to payment; (b) are 

increasingly being reported electronically, and the cessation measures from The Joint Commission have not been 

fully converted electronically; and (c)  may be more difficult to implement and report on than other measure 

sets (Freund et al. 2008, 2009). If the Joint Commission 
A Report of the Surgeon General

596 Chapter 7

cessation measures are not included in a CMS rule, otherwise tied to payment, or required, the number of acute 

care hospitals reporting on these measures will likely 

continue to decline. In contrast, two of these measures 

(offering cessation counseling and medication during hospitalization and again at discharge) are embedded in the 

Inpatient Psychiatric Facility Quality Reporting Program, 

and inpatient psychiatric facilities are required to report 

on these measures (CMS 2006).

Effective October 1, 2016, as part of its fiscal year 

2017 payment determination, CMS required inpatient 

psychiatric facilities to begin reporting on the first two 

tobacco cessation performance measures from The Joint 

Commission. CMS extended this requirement to the third 

Joint Commission cessation measure effective October 1, 

2017, as part of its fiscal year 2018 payment determination, and then discontinued the first measure for fiscal 

year 2019. These requirements, which embedded The 

Joint Commission’s measures in the Inpatient Psychiatric 

Facility Quality Reporting Program, are associated with an 

increase in the delivery of tobacco cessation treatments in 

psychiatric facilities. Specifically, Carrillo and colleagues 

(2017) documented a 10-fold increase in the number of 

smokers who received inpatient tobacco cessation treatment after CMS implemented the requirement.

To realize the full potential of The Joint Commission’s 

tobacco measures, reporting on those measures must be 

tied to payment. Currently, for acute care general hospitals, these measures are available for selection on a voluntary basis. As described previously, hospitals have several other sets of measures to pick from, and there is no 

incentive for them to select the tobacco cessation measures. Nonetheless, voluntary implementation of The 

Joint Commission’s cessation measures in acute care general hospitals has been associated with increased intervention rates. For example, between 2014 and 2015, among 

365 hospitals reporting data on The Joint Commission’s 

tobacco measures in place at that time, the rate of 

screening for tobacco use increased from 94.1% to 97.8%; 

the rate at which treatment (brief counseling or NRT) 

was provided or offered during hospitalization increased 

from 51.2% to 60.5%; and the rate at which treatment was 

provided or offered at discharge increased from 36.4% to 

40.6% (The Joint Commission 2016). A 2017 study found 

that EHRs can be leveraged to facilitate integration of The 

Joint Commission’s tobacco measures into routine inpatient care; the study reported a modest increase in orders 

for cessation medications (OR  =  1.35; 95% CI, 1.07–

1.70) and a 10-fold increase in rates of cessation counseling (OR = 10.54; 95% CI, 7.87–14.12) (Shelley et al. 

2017). Although only limited data are available to assess 

the impact that The Joint Commission’s tobacco measures have had on increasing quit attempts and successful 

cessation, brief interventions that include screening for 

tobacco use and provision of brief counseling and/or medication have been shown to double the likelihood of successful quitting (Fiore et al. 2008).

Chapter 6 discusses the benefits of intensive bedside 

treatment (Rigotti et al. 2014; Mullen et al. 2015; Nahhas 

et al. 2017; Cartmell et al. 2018). Requiring hospitals to 

provide bedside counseling to patients who use tobacco 

and to provide these patients with cessation prescriptions 

and follow-up appointments for cessation counseling at 

discharge could facilitate the adoption of tobacco treatment across the continuum of acute care, rehabilitation 

treatment, and outpatient treatment (Fiore et al. 2012). 

This approach would make the treatment of tobacco 

dependence consistent with the treatment of other chronic 

conditions and could also generate increased patient referrals to face-to-face outpatient programs in hospitals and to 

state quitlines.

Realigning Payment Incentives

Another approach that has the potential to increase 

the availability, delivery, and efficacy of treatment for 

tobacco use and dependence in healthcare settings is the 

implementation of policies that align clinician and facility 

payment with the quality of care provided. Although 

tobacco-specific data are not yet available, broad-based 

payment reforms, such as value-based purchasing and 

bundled payments (i.e., payment for what a defined episode 

of care is predicted to cost), seek to reimburse clinicians or 

hospitals for the outcomes of care, rather than for separate services provided (as is the case with fee-for-service 

approaches). Although not designed expressly for tobacco 

dependence treatment, new payment models could make 

such treatment more of a focus for clinicians and hospitals because tobacco use causes and exacerbates many 

common and costly diseases, may lead to hospital readmissions, and delays and complicates healing—all of which 

increase costs for the healthcare system (USDHHS 2014). 

Two other approaches of reimbursement for hospitals and 

physicians also have the potential to increase the delivery 

of evidence-based cessation interventions: (a)  allowing a 

wider variety of clinicians to bill for brief tobacco interventions and (b) expanding scope of practice to allow pharmacists to write prescriptions for cessation medications.

Alternative quality contracts (AQCs) are another 

policy mechanism that could enhance and improve the 

provision of tobacco use and dependence treatment. Such 

contracts, which are initiated by insurers, combine incentives to reduce healthcare spending with incentives to 

improve the quality of healthcare. Clinician groups share 

(a) the benefits of reducing costs (savings) and the financial risks of increased expenditures and (b) the opportunity 

to earn bonuses for improved quality of care. National data 
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 597

Smoking Cessation

are not yet available on AQCs, but early regional findings 

suggest that such strategies may increase rates of delivering tobacco cessation treatments. For example, in 2009, 

Blue Cross Blue Shield of Massachusetts established an 

AQC that was designed to pay healthcare service delivery 

systems a global fixed payment for all the services used 

by a covered population. Because they face a fixed budget 

for care delivered, health systems participating in AQCs 

have an incentive to emphasize preventive interventions, 

including those for tobacco use and dependence, that 

have been shown to reduce downstream healthcare costs. 

Huskamp and colleagues (2016) assessed the impact of the 

Massachusetts AQC on rates of the use of clinical smoking 

cessation services. The study found that rates of tobacco 

cessation treatment use were modestly higher among persons in AQC provider organizations than among those in 

non-AQC provider organizations: 2.02% vs. 1.87%, overall; 

4.97% vs. 4.66 %, among enrollees at risk for tobaccorelated complications; and 3.67% vs. 3.25%, among users 

of behavioral health services.

Enhancing the Technology of 

Electronic Health Records

EHRs are an important tool to improve the frequency, quality, and consistency of screening for tobacco 

use and dependence treatment, thereby increasing adherence to the Clinical Practice Guideline (Linder et  al. 

2009; Boyle et al. 2014). EHRs can also be used to connect persons who use tobacco with tobacco quitlines, text 

message-based support for cessation, and other clinical 

or community-based treatment resources by electronically referring patients to those services (i.e.,  through 

electronic referrals or eReferrals) (Greenwood et al. 2012; 

Kruse et  al. 2012). Federal and state programs to promote the adoption and use of EHRs and health information technology have provided incentives to clinicians 

and healthcare systems to transition from paper records 

to EHRs and to use EHRs in ways that are intended to 

improve the quality, safety, efficiency, and coordination of healthcare while reducing health disparities (The 

Commonwealth Fund n.d.). For example, the HITECH 

Act of 2009 was designed, in part, to promote the adoption and use of health information technology, including 

EHRs. Early on, HITECH provided financial incentives to 

Medicare- and Medicaid-eligible professionals and hospitals that adopted and demonstrated “Meaningful Use” of 

EHRs through the Medicare and Medicaid EHR Incentive 

Programs (Berwick et  al. 2008; Institute for Healthcare 

Improvement 2009), and Medicaid continues to provide 

those incentives. Meaningful Use criteria have included 

requirements regarding the documentation of patients’ 

tobacco use and, for outpatient tobacco clinical quality 

measures, the delivery of cessation treatments for patients 

who use tobacco.

By 2017, 86% of office-based physicians had adopted 

EHRs, up from 42% in 2008 (Office of the National 

Coordinator for Health Information Technology 2019). In 

addition, 56% of eligible professionals and 97% of eligible 

hospitals and critical access hospitals (a designation given 

to eligible rural hospitals designed to improve access to 

healthcare in these communities) have participated in the 

Medicare and Medicaid EHR Incentive Programs. Through 

October  2018, eligible professionals and hospitals had 

received more than $38 billion from the program as part 

of incentive payments through Medicare and Medicaid 

reimbursement for adopting certified EHR technology and 

for using EHRs to achieve specified performance and technology objectives (i.e.,  demonstrating meaningful use) 

(CMS 2018).

As part of the EHR Incentive Programs, eligible professionals and hospitals are evaluated on their rates of asking 

about and documenting (in their EHRs) cigarette smoking 

status for patients 13  years of age and older. Meeting 

this measure has been a requirement for receiving payments through the Medicare and Medicaid EHR Incentive 

Programs, which is important because the assessment of 

smoking status is a critical first step for engaging patients 

in cessation treatment (see Chapter  6). For established 

users of EHR technology (Stage 2 of Meaningful Use), eligible professionals and hospitals must demonstrate that 

they use their EHRs to document the smoking status of 

at least 80% of their patients, 13 years of age and older, 

to receive performance payments through the program. 

By 2016, more than 97% of hospitals and eligible professionals that were reporting to the EHR Incentive Programs 

had met the requirement of documenting smoking status 

for patients visiting their healthcare facilities (CMS 2016).

In addition to encouraging the identification of 

patients who use tobacco, the EHR Incentive Programs 

include an electronic clinical quality measure to assess 

whether eligible professionals and hospitals provide cessation counseling services to patients identified as smokers 

and whether that counseling is documented in patients’ 

EHRs. Although not required, this clinical quality measure encourages eligible professionals and hospitals to 

move beyond documenting tobacco use status to delivering evidence-based cessation counseling. In the United 

States, clinical quality measures and related financial 

incentives have been major influences on clinician performance for more than a decade (Papadakis et al. 2010; 

Thomas et al. 2017). Clinical quality measures help to 

drive accountability for eligible professionals and hospitals, and the resulting feedback helps to improve medical 
A Report of the Surgeon General

598 Chapter 7

care. Accordingly, the EHR Incentive Programs and other 

incentive-based efforts to increase and improve the use 

of EHRs have the potential to increase the rates at which 

tobacco use is identified, documented, and treated when 

these initiatives are structured to integrate proven clinical 

tobacco cessation interventions into EHRs (Boyle et  al. 

2014; Schindler-Ruwisch et al. 2017).

Fiore and colleagues (2019) studied eReferrals to the 

Wisconsin quitline in which 23 primary care clinics from 

two healthcare systems were randomized to one of two 

methods for referring to the quitline adult patients who 

smoke: a paper-based fax-to-quit referral process or an 

eReferral process. The eReferral process involved sending 

referrals from patients’ EHRs to the quitline and receiving 

back into these EHRs outcome reports from the quitline. 

The fax referral process involved transmitting the same 

information in both directions via fax. The two systems 

saw a combined 14,636 smokers. Compared with clinics 

that were randomized to the fax referral process, clinics 

that were randomized to the eReferral process generated 

quitline referral rates 3–4 times higher and also connected 

patients with quitlines at higher rates (i.e., having patients 

accept a quitline call and at least begin the process or registering for quitline services). The eReferral method generated especially high rates of referrals among Medicaid 

recipients. The study, which was the first randomized 

study on this topic, concluded that eReferrals provide an 

effective way to refer patients who smoke to quitline services (Fiore et al. 2019).

Overall, the evidence is suggestive, but not sufficient, to infer that EHR technology increases the rate of 

delivery of smoking cessation treatments.

Population-Based Strategies on Smoking Cessation

In addition to strategies that can be implemented 

to increase the provision of clinical interventions to help 

smokers quit, broader population-level tobacco control 

strategies can also have important effects on tobacco cessation. This section reviews (1)  strategies and programs 

that increase access to and use of evidence-based cessation 

treatments at the population level (e.g., funding tobacco 

quitlines) and (2) strategies that affect quit attempt rates, 

quit success rates, and smoking prevalence at the population level, without necessarily directly influencing cessation support or treatment at the individual level (e.g., price 

or smokefree laws). Several interventions can fit into both 

of these categories (e.g.,  mass media campaigns, state 

tobacco control programs, pictorial health warnings, verylow-nicotine-content cigarettes). Policy and regulatory 

details related to very-low-nicotine-content cigarettes and 

e-cigarettes are also described in this chapter. (Chapter 6 

presents details about very-low-nicotine-content cigarettes 

and e-cigarettes as they relate to cessation outcomes.) The 

population-based strategies discussed in this chapter are 

reviewed in the context of their effects on smoking cessation. However, many of these strategies have broader 

effects. A review of these broader effects is beyond the 

scope of this report. The 2014 Surgeon General’s report 

includes additional information on the broader effects of 

many of these strategies (USDHHS 2014).

Quitlines

Although telephone quitlines are a cessation treatment, they are included in this section on macro-level 

policy actions because they are designed to be accessed on 

a population-wide basis and are supported through broad 

policies, including funding at the state and federal levels. 

This chapter focuses on quitlines as an evidence-based, 

population-level strategy and on their relationships with 

cessation insurance coverage requirements and measures 

of treatment quality. Chapter 6 also addresses quitline services but focuses on their role as cessation treatments and 

discusses their effectiveness and reach.

Tobacco quitlines have typically been funded at the 

state level (Beyer et al. 2010), but they can also be used and 

funded by employers, health plans, and health systems. 

Quitlines offer a convenient solution to helping health 

insurers partially meet the ACA requirements for tobacco 

cessation coverage (Lemaire et al. 2015); they can be used 

by employers as an employee benefit to promote quitting, 

help increase employee productivity, and reduce health 

expenditures related to tobacco use (Hughes et al. 2011). 

Similarly, health systems can use quitlines as an adjunct to 

clinical care and to provide ongoing follow-up support to 

patients who are engaged in a quit attempt (Warner et al. 

2012). Finally, health systems can leverage quitlines as a 

means to reduce hospital readmission rates and to meet 

tobacco use and dependence treatment quality measures.

A variety of models exist for employers, health plans, 

and health systems to establish and leverage quitline services, including (1) contracting directly with quitline vendors and other entities for their services; (2) providing 

funds to the state quitline to cover the costs incurred 

from directing employees, members, and patients to the 

state quitline; or (3) having their employees, members, or 

patients use state-funded quitline services without cost 
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 599

Smoking Cessation

sharing. The third model is less than ideal for the financial 

sustainability of state quitlines. Although this has been 

the default approach in many states, several states have 

sought to bring health plans and employers to the table 

to share costs and help sustain quitline services, especially in times of funding reductions for state quitlines. 

Funding for both service provision and promotion is a primary factor that can limit the reach of quitlines (North 

American Quitline Consortium 2016).

As briefly described in Chapter 6, quitlines are 

increasingly serving as “extended treatment” for busy clinicians. The first method that healthcare providers used 

to refer patients to quitlines is the passive approach of 

simply giving patients information on how to contact 

the quitline (e.g., a card or brochure with the quitline’s 

number). In practice, few patients follow through and 

call the quitline. This method gradually gave way to a 

second approach: having healthcare personnel fax contact 

information for patients to the quitline (the “fax-to-quit” 

method). Quitlines then proactively call patients to deliver 

treatment. By 2009, all 50 states, the District of Columbia, 

Puerto Rico, and Guam reported offering fax referral services, although fax referral programs and implementation 

varied widely across locations. Despite including a proactive step to connect patients with the quitline, fax referrals 

can be cumbersome and time-consuming (Cantrell and 

Shelley 2009). For example, staff at quitlines sometimes 

had trouble reading clinicians’ handwriting. In addition, 

clinic staff often used fax referrals inconsistently (Sheffer 

et al. 2012), or required an intensive program to promote 

and routinize the use of fax referrals (Redmond et al. 2010; 

Schauer et al. 2012; Warner et al. 2012).

Recent efforts have focused on using EHR technology to “eRefer” patients who smoke to the state’s quitline (Boyle et al. 2011; Vidrine et al. 2013; Sharifi et al. 

2014). This involves having clinicians make a HIPAA 

(Health Insurance Portability and Accountability Act of 

1996)-compliant eReferral to a quitline, which may be 

operated by a vendor contracting with the state tobacco 

control program, health plan, employer, wellness vendor, 

or other entity. The healthcare provider sends an eReferral 

to the quitline with key information that identifies the 

patient (e.g., name, telephone number, best time to call). 

This prompts staff at the quitline to attempt to call the 

patient to deliver cessation services. Finally, the quitline closes the loop by sending an eReferral back to the 

patient’s EHR with information about the outcome of the 

referral (e.g., was the patient successfully contacted, did 

the patient set a quit date, did the patient receive counseling or medication, did the patient make a quit attempt 

and successfully quit). This type of bidirectional, closedloop approach is the most effective approach to implementing eReferrals (North American Quitline Consortium 

2015), in part because hearing back from the quitline 

enables the provider to follow up with the patient and support any tobacco cessation attempt.

Data suggest that direct eReferrals to a quitline are 

more effective in connecting patients with that quitline 

than either traditional fax referral or passive referral, in 

which a tobacco user receives a business card or other materials featuring the phone number of the quitline; and both 

eReferral and fax referral offer benefits over passive referral 

because they proactively contact the patient to begin services. In a pilot study of eReferrals, Adsit and colleagues 

(2014) found that 14% of adult smokers who had visited an 

outpatient clinic were referred to the quitline via eReferral, 

while only 0.3% were referred using the traditional fax 

method. Elsewhere, Vidrine and colleagues (2013) conducted a two-arm, group-randomized study of 10 matched 

family practice clinics that compared eReferral to a quitline 

that used the passive referral approach of handing patients 

business cards for the quitline. Of all identified smokers in 

treatment, 7.8% were referred using eReferral, and 0.6% 

were referred through a passive referral (OR = 11.6; 95% 

CI, 5.5–24.3). EReferral serves as a good example of the 

complementary effects that can occur when healthcare 

systems respond to policy initiatives. The Meaningful Use 

program was effective in accelerating healthcare systems’ 

adoption of EHR systems. In turn, eReferrals leverage these 

EHR systems to link healthcare systems with quitline services in a more seamless, consistent, and effective way.

Overall, the evidence is sufficient to infer that tobacco 

quitlines are an effective population-based approach to 

motivate quit attempts and to increase smoking cessation. 

Quitlines can be connected to health systems with EHRs 

to further facilitate and routinize the use and utility of 

quitlines.

Increasing the Price of Tobacco 

Products

Increasing the price of cigarettes, such as through 

taxation, is one of the most effective strategies for reducing 

cigarette consumption (USDHHS 2014). Cigarette price 

increases reduce cigarette consumption and smoking prevalence by leading some smokers to quit and some smokers 

to smoke fewer cigarettes per day and also reduce the 

number of young persons who initiate smoking (DeCicca 

and McLeod 2008; Reed et  al. 2008; Bader et  al. 2011; 

Chaloupka et  al. 2011; Ross et  al. 2011; Vijayaraghavan 

et  al. 2013; Ross et  al. 2014; USDHHS 2014; NCI and 

WHO 2016; Stevens et al. 2017). A comprehensive review 

by Chaloupka and colleagues (2011), which was summarized in the 2014 Surgeon General’s report (USDHHS 

2014), concluded that a 10% increase in cigarette price 
A Report of the Surgeon General

600 Chapter 7

would result in a 3–5% reduction in overall cigarette consumption. That review also concluded that increases in 

cigarette prices would result in decreases in the prevalence of smoking and in the average number of cigarettes 

smoked. In its report on the global tobacco epidemic, 

WHO (2017) concluded that raising taxes to increase the 

price of tobacco products is the most effective and costeffective means to reduce tobacco use and encourage cessation. Moreover, reports from WHO (2017) and the U.S. 

Surgeon General (USDHHS 2012b, 2014) have concluded 

that youth and lower income populations are especially 

sensitive to price increases. 

Research has demonstrated that price increases 

can also influence tobacco cessation at the national and 

state levels. Specifically, data indicate that price increases 

are associated with increases in motivation to quit, quit 

attempts, and rates of cessation at the population level 

(Chaloupka et al. 2002; Ross et al. 2011; Bush et al. 2012; 

Chaloupka et al. 2012; Choi and Boyle 2013; Scollo et al. 

2013). For example, Stevens and colleagues (2017) found 

that each $1.00 increase in the average price of cigarettes 

was associated with a 6% increase in the quit rate of U.S. 

smokers 50 years of age and older.

The U.S. Community Preventive Services Task Force 

recommended increasing the unit price of tobacco products based on strong evidence that such a price increase is 

effective at reducing tobacco use (The Community Guide 

2012a). The Task Force reported that this effect is driven, 

in part, by an increase in the number of persons who quit. 

The Task Force reported that for every 10% increase in 

price, there is a 3.8-percentage-point increase in cessation 

(The Community Guide 2013). More recently, NCI and 

WHO (2016) noted that only a few studies have used longitudinal data to examine the specific relationship between 

taxes or prices and cessation. Those studies generally found 

that higher prices increase the likelihood of smoking cessation (Tauras and Chaloupka 1999; Tauras 2004; Hyland 

et al. 2006; DeCicca et al. 2008; Ross et al. 2014). In particular, longitudinal data from the United States and Canada 

found evidence that (a) smokers living in areas with higher 

cigarette prices are significantly more motivated to quit, 

(b)  price increases for cigarettes over time appear to 

increase motivation to quit, and (c) higher cigarette prices 

increase the likelihood of actual quitting (Ross et al. 2011).

In addition to national examples, robust findings 

for price-related outcomes at the state level indicate that 

price increases have both short- and long-term effects. 

For example, Reed and colleagues (2008) assessed rates 

of smoking cessation in California after an increase in the 

state’s cigarette excise tax and a subsequent increase in 

retail prices by a cigarette manufacturer. For the months 

immediately following cigarette price increases, data from 

the 1996 and 1999 California Tobacco Surveys showed a 

significant increase in the proportion of smokers reporting 

quit attempts (a 45% year-over-year increase from 1995 

to 1996 and a 140% increase after the excise tax went 

into effect in December 1998, p <0.05), and a significant 

increase in abstinence rates (a 94% year-over-year increase 

from 1995 to 1996 and a 120% increase after the excise tax 

went into effect in December 1998, p <0.05). In addition, 

Tseng and colleagues (2014) used a health informatics 

system to assess the impact of an increase in the federal cigarette tax on readiness to quit among low-income smokers 

in Louisiana. In the month following the increase, readiness to quit rose from 22% before the increase to 33%.

Increasing the price of cigarettes would also be 

expected to lead to smoking fewer cigarettes per day; however, the design of cigarettes has also changed over time 

in ways that allow smokers to more easily modify their 

nicotine intake (USDHHS 2010; Land et al. 2014). Jarvis 

and colleagues (2014) reported that today’s smokers may 

smoke fewer cigarettes, but the nicotine yield per cigarette 

(based on cotinine levels) has increased 42% from 1988 to 

2012. Thus, future research should address (a) how much 

smokers are compensating for reduced cigarette consumption by smoking more efficiently, (b) the effects of 

contemporary cigarettes, and (c) how these factors affect 

overall population health.

Although price increases have a strong impact on 

cessation at the population level, some recent data suggest 

that impacts may differ across subpopulations. For example, 

an analysis of data from the Tobacco Use Supplement to 

the Current Population Survey in the United States found 

that price is positively associated with (a)  intention to 

quit among non-Hispanic White smokers (p  <.001) and 

non-Hispanic African American smokers (p  <.001) and 

(b)  quit attempts among non-Hispanic White smokers 

(p <.001) but not among non-Hispanic African American 

smokers (Keeler et al. 2018). As another example, qualitative studies conducted in New York suggest that some 

low-income smokers may circumvent price increases by 

purchasing untaxed cigarettes from Native American reservations, bootlegged cigarettes, and/or single cigarettes 

or by taking advantage of discounts and coupons from the 

tobacco industry (Shelley et al. 2007; Curry et al. 2018). 

However, it is important to note that increasing the price 

of tobacco products does not automatically result in the 

creation of substantial black markets (National Research 

Council 2015). Although taxes and price differentials on 

tobacco products can create incentives for tax evasion, 

several environmental and administrative factors play an 

equal or greater role, including high levels of corruption, 

lack of commitment to addressing illicit trade, and ineffective administration of customs charges and taxes (NCI 

and WHO 2016). Substantial evidence from many countries shows that illicit trade can be prevented as the price 
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 601

Smoking Cessation

of tobacco rises, resulting in increased tax revenues and 

reduced tobacco use (NCI and WHO 2016).

U.S. tobacco price increases in the form of excise 

taxes have become an important source of state government revenues (Boonn 2017, 2018), contributing $13–

$15 billion annually to state and federal government revenues (Orzechowski and Walker 2017), but little of that tax 

revenue is invested in tobacco control and cessation efforts 

(CDC 2012b). Because state tobacco control expenditures 

are correlated with decreased prevalence of tobacco use 

and increased use of evidence-based cessation treatments, 

funding of public education and treatment support related 

to tobacco cessation through excise taxes, along with funds 

from the Master Settlement Agreement (MSA) and other 

funds, could have a large impact on cessation (Ossip-Klein 

and McIntosh 2003; Farrelly et al. 2008; USDHHS 2014).

In summary, policies increasing the price of tobacco 

products have two important outcomes for tobacco cessation: (1) they provide incentives that can increase motivation to quit, decrease cigarette consumption, and drive 

smokers to make quit attempts; and (2) they provide a possible revenue stream to support evidence-based tobacco 

control strategies, including tobacco cessation activities. 

As policy makers consider increases in the price of tobacco 

products, they may consider ensuring that cessation services are funded and available to meet the increased 

demand. Large increases in price can be particularly effective in reducing smoking among vulnerable populations, 

including young people and individuals with lower socioeconomic status. Overall, the evidence is sufficient to infer 

that increasing the price of cigarettes reduces the prevalence of smoking, reduces cigarette consumption, reduces 

the average number of cigarettes smoked, and increases 

smoking cessation.

Smokefree Policies

The number of state and local laws that prohibit smoking in indoor public places and workplaces—

including restaurants and bars—has increased rapidly in 

the past two decades (USDHHS 2014). As of June 30, 2018, 

27 states and the District of Columbia had implemented 

comprehensive smokefree laws that prohibit smoking in all 

indoor areas of private sector worksites, restaurants, and 

bars (Centers for Disease Control and Prevention 2018a). 

In many states without comprehensive smokefree laws, 

local smokefree ordinances have protected substantial proportions of the state population (Tynan et al. 2016). As of 

October 1, 2019, 61% of the U.S. population is protected by 

a comprehensive state or local smokefree law (American 

Nonsmokers’ Rights Foundation 2019b). Additionally, several jurisdictions have removed exemptions and included 

such areas as casinos and other gaming facilities in these 

laws (American Nonsmokers’ Rights Foundation 2019a).

Although smokefree laws are primarily intended 

to eliminate involuntary exposure to secondhand smoke 

indoors, thereby protecting nonsmokers from the health 

risks of exposure to secondhand smoke, a substantial body 

of evidence has documented an association between the 

implementation of smokefree laws at the local, state, and 

national levels and decreased smoking among populations influenced by smokefree policies (USDHHS 2014). 

For example, USDHHS (2006) concluded that smoking 

restrictions in the workplace lead to less smoking among 

workers, and WHO (2009) concluded that smokefree workplaces reduce cigarette consumption among continuing 

smokers and lead to increased successful cessation. The 

impact of smokefree policies on cessation can be maximized when these policies are coupled with the promotion 

of free cessation resources (USDHHS 2006; International 

Agency for Research on Cancer [IARC] 2009).

The Community Guide (2012b) presented a systematic review on the effects of smokefree policies and concluded that smokefree policies increase the number of 

tobacco users willing to quit (reported as a mean absolute 

increase of 3.8 percentage points). Hopkins and colleagues 

(2010) reviewed 57  studies published between 1976 and 

2005 and found that smokefree policies were associated 

with a median decrease of 3.4  percentage points (interquartile interval: -6.3  to -1.4  percentage points) in the 

prevalence of cigarette use and an absolute increase of 

6.4 percentage points (interquartile interval: 1.3–7.9 percentage points) in cessation. The authors concluded that 

“the results of this review suggest that smokefree policies reduce consumption by continuing smokers, increase 

smoking cessation attempts, increase the number of 

smokers who successfully quit, and reduce the prevalence 

of tobacco use among workers” (p. S285).

Fichtenberg and Glantz (2002) reviewed 26 studies 

that evaluated the impact of smokefree ordinances at worksites and found that such ordinances were associated with 

a 3.8% (95% CI, 2.8–4.7%) reduction in the prevalence of 

smoking and 3.1% (95% CI, 2.4–3.8%) fewer cigarettes 

smoked among persons who continued to smoke. Other 

analyses found higher rates of smoking cessation at worksites that implemented smokefree policies (Longo et  al. 

2001); greater self-reported interest in quitting (Hammond 

et al. 2004); and a greater likelihood of smoking cessation 

the longer the smokefree policy was in effect (comparing 

rates of quitting at 18 and 36 months after implementation 

of a smokefree ordinance) (Hahn et al. 2009).

With the increasing adoption of smokefree policies 

in indoor public places and workplaces, private settings are 

becoming the major remaining source of exposure to secondhand smoke for many individuals. Residents of multiunit 
A Report of the Surgeon General

602 Chapter 7

housing are particularly likely to be exposed to secondhand 

smoke in their homes. An estimated 80 million people in 

the United States, or 25% of the U.S. population, reside in 

multiunit housing (King et al. 2013a). A subset of those 

individuals resides in government-subsidized housing, 

including public housing. Recent data indicate increases 

in the implementation of smokefree policies for subsidized, 

multiunit housing sites (Pizacani et  al. 2012). Notably, 

the U.S. Department of Housing and Urban Development 

(2016) finalized a rule requiring public housing authorities to prohibit smoking in their buildings, including 

inside residents’ units. The policy was coupled with promotion of tobacco cessation and cessation resources. This 

policy could help motivate many smokers to quit and may 

also encourage more private multiunit housing facilities to 

adopt similar policies (Levy et al. 2017a).

Promoting cessation resources in conjunction with 

the implementation of smokefree multiunit housing policies can help to facilitate the successful implementation 

of such policies and maximizes their impact on cessation. 

Increasing the adoption of smokefree policies in public 

and private multiunit housing and the availability of free 

cessation services to residents of multiunit housing is also 

important from a health equity standpoint because many 

residents of multiunit housing are from disadvantaged 

populations, including low-income persons, persons with 

behavioral health conditions, persons of minority racial/

ethnic groups, persons with disabilities, elderly persons, 

and children. These populations are more likely to smoke 

cigarettes and/or to be exposed to secondhand smoke 

due to a variety of factors, and they often have less access 

to healthcare, including smoking cessation treatments 

(USDHHS 2006; CDC 2014a; Jamal et al. 2018).

In addition to federal progress making government 

subsidized housing smokefree, as of October  1, 2019, 

more than 56 cities and counties have local laws requiring 

smokefree policies in all multiunit housing, including both 

government or subsidized and private-market rate housing 

(American Nonsmokers’ Rights Foundation 2019c). Data 

have shown that the adoption and maintenance of household smokefree rules in private single-family homes 

and smokefree policies in subsidized and public multiunit housing are associated with decreased consumption 

of cigarettes, increased confidence in achieving cessation, increased potentially considerable cost savings, and 

greater prevalence of successful cessation (Messer et  al. 

2008; Hyland et  al. 2009; Kegler et  al. 2012, 2015; King 

et al. 2014).

Smokefree restrictions can also be established in 

single-family homes to protect household members and to 

create an environment that can promote and support cessation (USDHHS 2006; IARC 2009). Household rules are 

voluntarily made by the occupants of the home (USDHHS 

2006). Several studies have found that having rules in 

place for a smokefree home helps to prevent smoking 

relapse and increases other cessation behaviors, including 

quit attempts and successful cessation (Farkas et al. 1999, 

2000; Gilpin et  al. 1999; Borland et al. 2006; USDHHS 

2006; Hyland et al. 2009; IARC 2009). Rules for a smokefree home can also support smoking cessation by making 

smoking more inconvenient, delaying smoking initiation, disrupting smoking rituals, and causing smokers to 

reduce their daily cigarette consumption (USDHHS 2006; 

IARC 2009). Coaching interventions can be (a) an effective 

way to motivate persons to establish rules for a smokefree 

home (Kegler et al. 2012; Escoffery et al. 2017; Bundy et al. 

2018) and (b)  delivered in a brief format through 2-1-1 

telephone helplines that are set up with the primary goal of 

providing low-income populations with support and linkages to essential health and human services (Kegler et al. 

2015; Mullen et al. 2016; Williams et al. 2016; Bundy et al. 

2018; Thompson et al. 2019). Although beyond the scope 

of this report, a smaller body of research suggests that 

rules for a smokefree home can also prevent youth from 

starting to smoke and perhaps help youth quit smoking, in 

part by functioning as an expression of antismoking norms 

(Farkas et  al. 2000). IARC (2009) concluded that policies for a smokefree home reduce adult smoking, youth 

smoking, and children’s exposure to secondhand smoke.

Healthcare facilities are another important setting 

in which to implement smokefree or tobacco-free policies 

(Sheffer et al. 2009). Behavioral health treatment facilities, 

including mental health and substance use treatment facilities, are important because of the disproportional impact 

of tobacco use on populations with behavioral health 

comorbidities (Marynak et al. 2018). Despite attempts in 

the 1990s to explore the feasibility and acceptability of 

implementing smokefree policies in mental health and 

substance use treatment settings and taking other steps 

to address the high rates of smoking among persons with 

behavioral health conditions (Patten et  al. 1996), many 

mental health and substance use providers and treatment 

facilities have been reluctant to implement tobacco-free 

facility policies and to integrate tobacco use and dependence treatment into routine clinical care (Schroeder 

et al. 2017). This may be due, in part, to some misconceptions implying that persons with behavioral health conditions do not want to quit and/or are not able to quit, and 

that helping smokers quit might undermine recovery from 

mental health problems and substance use (Schroeder 

and Morris 2010; American Legacy Foundation 2011; 

Prochaska 2011; CDC 2013b; USDHHS 2014). In addition, 

the tobacco industry has opposed smokefree polices in 

psychiatric hospitals, donated cigarettes to mental health 

facilities, and funded research suggesting that patients 

with psychiatric illnesses need tobacco for self-medication 
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 603

Smoking Cessation

(CDC 2013b; Prochaska et al. 2017; Marynak et al. 2018). 

However, attitudes toward such polices are changing, 

and mental health and substance use treatment facilities 

have increasingly begun to incorporate tobacco cessation into their missions, driven by greater efforts to integrate behavioral healthcare with primary healthcare, an 

increasing emphasis by behavioral health providers on a 

holistic approach that addresses patients’ overall health 

and well-being, and the recognition that persons with 

behavioral health conditions are disproportionately likely 

to die prematurely of a smoking-related disease (USDHHS 

2014; Schroeder et al. 2017). These efforts have coincided 

with increased adoption of smokefree and tobacco-free 

policies, including campuswide policies, by state behavioral health facilities (Marynak et al. 2018).

Overall, the evidence is sufficient to infer that smokefree policies reduce the prevalence of smoking, reduce 

cigarette consumption, and increase smoking cessation. 

Coupled with the aforementioned evidence, data also indicate that smokefree policies are particularly effective when 

coupled with the promotion of resources for cessation. 

Specifically, the Community Guide (2012b) notes that 

to maximize cessation outcomes, the implementation of 

smokefree policies should include the provision and promotion, including through quitlines, of proven cessation 

resources, such as counseling and medication.

Mass Media Campaigns

Scientific evidence shows that mass media educational campaigns can effectively motivate tobacco 

users to make quit attempts and promote tobacco cessation at the population level (NCI 2008; USDHHS 2014). 

Some hard-hitting advertisements (ads) seek to motivate 

smokers to quit by depicting the health consequences 

of continued smoking in emotionally compelling ways 

through graphic pictorial images and/or personal testimonials (Durkin et al. 2012). Other ads take a gain-frame 

approach by emphasizing the benefits of quitting rather 

than the losses associated with smoking (Toll et al. 2007). 

The latter type of ads is generally not as effective in motivating quit attempts as the type of ads that focuses on the 

health consequences of smoking and evokes fear or negative emotions (Durkin et al. 2012, 2018). Very few ads and 

no ad campaigns have attempted to systematically provide 

smokers with evidence-based recommendations on how to 

quit smoking, as recommended in the Clinical Practice 

Guideline (i.e., set a quit date in the near future; abstain 

from all cigarettes; remove all smoking-related paraphernalia; consider use of counseling and medications; and 

avoid high-risk social situations, especially use of alcohol, 

during the first weeks of a quit attempt [Fiore et al. 2008]).

Examples of Campaigns

The Fairness Doctrine campaign of 1967–1970 

required stations broadcasting cigarette commercials 

to donate air time for antismoking messages that would 

provide the public, for the first time on television, with 

advertisements that countered messages from the tobacco 

industry (USDHHS 2014). In 2008, following a number 

of media campaigns in individual states, the Legacy 

Foundation (now known as Truth Initiative) launched 

EX, the first national adult cessation campaign since the 

Fairness Doctrine (Vallone et al. 2011). EX ran on television and radio from March 31 to September 28, 2008, and 

was targeted to adult smokers 25–49 years of age (Villanti 

et al. 2012).

In 2012, CDC launched Tips From Former Smokers, 

the first federally funded, national tobacco education 

campaign. This campaign provides a particularly strong 

example of the impact that mass media campaigns can have 

on adult smoking cessation at the national level. The Tips

campaign has been on air from 2012 to 2019 for varying 

durations, ranging from 12 weeks in 2012 to 29 weeks in 

2017. The hard-hitting, graphic testimonial campaign 

profiles real people who are living with serious long-term 

health effects from smoking and exposure to secondhand 

smoke (McAfee et al. 2017). Media placements vary from 

year to year, and the national ad buy has included placements on national broadcast, cable television, and digital 

properties. The national media campaign has been supplemented with additional ad placements in local media markets that have the highest rates of smoking. The media 

placements are designed to reach low-income and other 

groups that have the highest rates of smoking.

In addition to motivating smokers to quit, the Tips

campaign also directs smokers to services that can provide 

them help with quitting. All ads in the Tips campaign promote a free source of cessation assistance: either the national 

quitline portal, 1-800-QUIT-NOW, which routes callers, 

based on their area code, to the quitline in their state, or 

a website that contains information to help smokers quit.

In January 2018, FDA launched Every Try Counts, 

the agency’s first smoking cessation campaign. Every 

Try Counts builds on research that shows it takes many 

smokers multiple attempts to achieve long-term cessation 

(USDHHS 2014). The campaign aims to increase motivation to quit among adult smokers, 25–54 years of age, who 

have tried to quit smoking in the past but were unsuccessful. Complementary to Tips From Former Smokers, 

Every Try Counts uses positive messaging to reframe 

past quit attempts as important steps toward future success and to underscore that quitting is a process. The 

campaign is active in media markets with a high prevalence of smoking among adults, and messages are delivered through geotargeted digital, radio, and outdoor print 
A Report of the Surgeon General

604 Chapter 7

advertisements. Each ad includes a call to action to drive 

smokers to the campaign’s website, which was developed 

in partnership with NCI, and features quitting tips, text 

message programs to help smokers “practice the quit,” 

and online cessation counseling.

Features of Antismoking Campaigns that Support 

the Use of Cessation Resources

Mass media antismoking campaigns are frequently 

tagged with phone numbers for quitlines, an approach 

that serves several purposes. From a marketing and psychological perspective, inclusion of the quitline number 

extends a helping hand to smokers and serves to soften the 

message of hard-hitting campaigns that feature emotional 

ads with graphic images or personal testimonials about 

the consequences of smoking. Studies of antismoking 

media campaigns have found this approach to advertising 

to be most effective (Wakefield et al. 2008). Marketing 

research suggests that when ads offer cessation help, 

smokers are more likely to consider and accept messages 

about negative smoking-related health consequences. 

From the quitline perspective, tagging mass media antismoking ads with quitline numbers is a cost-effective 

means of increasing calls to quitlines (CDC 2006; Sheffer 

et al. 2010). The effectiveness of tagging ads with a quitline number is illustrated in Figure 7.2.

In addition to quitline numbers, mass media antismoking ads have been tagged with website addresses 

that provide cessation support, including information 

about referral centers that can direct interested persons 

to a range of cessation resources, including in-person services (ClearWay Minnesota n.d.). Other means of advertising quitline services that have been shown to be effective include systematic encouragement of referrals from 

healthcare providers (Curry et al. 1998; Redmond et al. 

2010), which may also result in an improved capacity of 

healthcare systems to identify and engage with smokers 

because the quitline assists in follow-up. In addition, promotion of services emphasizing the availability of cessation 

Figure 7.2 Intensity of ad placement for Tips From Former Smokers (Tips) campaign and call volume to 

1-800-QUIT-NOW, 2013

Source: National Cancer Institute (unpublished data); The Nielsen Company (unpublished data).

Notes: Call volume for 1-800 QUIT-NOW and 2013 Tips campaign gross ratings points (GRPs) are measures of the intensity of ad 

media placement.
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 605

Smoking Cessation

medications has been shown to increase quit success and 

increase calls (An et al. 2006; CDC 2006; Hollis et al. 2007; 

USPSTF 2015).

Effectiveness of Campaigns

The Fairness Doctrine campaign was associated with 

significant declines in cigarette smoking rates among 

both adults and youth (Hamilton 1972). An evaluation 

of the EX campaign that focused on adult smokers who 

were aware of the campaign in eight media market areas 

at baseline and approximately 6 months later found that 

EX had significantly increased quit attempts (OR = 1.24; 

p = .048) (Vallone et al. 2011).

In several studies, the Tips campaign was found to be 

associated with rapid and substantial increases in calls to 

states’ quitlines, which persisted for the duration of each 

Tips campaign cycle (CDC 2012a, 2013a; Davis et al. 2015). 

The Tips campaign has also been associated with increases 

in visitors to the websites featured in Tips ads (CDC 2012a, 

2013a; Shafer et al. 2016). Although call volumes to quitlines provide a tangible early indicator of the Tips campaign’s impact, the campaign has a much broader impact on 

cessation, with many smokers indicating that they intend 

to quit smoking, that they tried to quit, or finally succeeded in quitting without ever calling a quitline. An analysis of nationally representative cohorts of 3,051 smokers 

who completed baseline and follow-up assessments during 

the first 3 months of the 2012 Tips campaign, found that 

quit attempts among smokers increased significantly from 

31.1% (95% CI, 30.3–31.9) to 34.8% (95% CI, 34.0–35.7). 

Moreover, 13.4% of smokers who reported making a quit 

attempt reported abstinence at follow-up. Although the 

3.2% absolute increase in quit attempts observed may 

seem small, this translates into an estimated 1.6 million 

additional smokers making a quit attempt, and an estimated 220,000  of these smokers remained abstinent at 

3-month follow-up (McAfee et  al. 2013; USDHHS 2014).

Analyses from the first year of the Tips campaign suggest

that the campaign saved an estimated 179,099  qualityadjusted life-years (QALYs) and prevented 17,109 premature deaths. The campaign was also cost-effective, costing

an estimated $480 per quitter, $2,819 per premature death

averted, $393  per life-year saved, and $268  per QALY

gained (Grosse 2008; Xu et al. 2015a). In the United States,

a commonly used threshold to consider an intervention

cost-effective from a societal perspective is $50,000  per

QALY gained (Xu et al. 2015a). In their evaluation of Tips,

Neff and colleagues (2016) found that (a) exposure to the

campaign was associated with increased odds of making a

quit attempt in the previous 3 months (OR = 1.17; 95% CI,

1.02–1.36, p <0.05) compared with baseline and (b) Tips

was associated with an estimated 1.8  million additional

quit attempts, suggesting that the effectiveness of the

campaign was not diminishing over time. Murphy-Hoefer 

and colleagues (2018) found that during 2012–2015, the 

Tips campaign was associated with approximately 9.15 million total additional persons who made a quit attempt and 

approximately 522,000 persons who quit smoking.

In 1997, Australia began a national tobacco cessation campaign with an intense and long-running 

mass media component that targeted adults (Hill and 

Carroll 2003). An analysis of quit attempts in a cohort of 

3,047 Australian smokers exposed to the national tobacco 

cessation television ad campaign between 2002 and 2008 

found that exposure to tobacco control advertising in the 

previous 3  months was associated with a greater likelihood of making a quit attempt, with each 1,000 increase in 

gross ratings points per quarter corresponding to an 11% 

increase in making a quit attempt (Wakefield et al. 2011).

In a detailed review of 70  studies (from January 

2000 to July 2012) about mass-reach health communications campaigns for tobacco cessation, The Community 

Preventive Services Task Force identified 64  studies that 

assessed intervention campaigns in which television was 

the primary medium. Overall, the mass-reach campaigns 

were associated with decreased prevalence of tobacco use, 

increased cessation, and increased use of available cessation 

services and decreased tobacco use initiation among young 

persons. The campaigns were associated with an average 

3.5-percentage-point absolute increase in cessation rates 

(2.0–5.0 in 12 studies); this translates to an approximate 

14% relative increase (The Community Guide 2013).

Studies also showed that a dose-response relationship 

between quitting rates and greater exposure to mass media 

campaigns was associated with increased calls to a quitline 

and increased quit rates (The Community Guide 2013). 

Since that review, Davis and colleagues (2012) reported a 

13% relative reduction in the prevalence of smoking and 

a 35% increase in quit attempts after a smoking cessation campaign in New York. Minnesota has also conducted 

extensive media campaigns to promote cessation, noting “a 

positive relation between weekly broadcast targeted rating 

points and the number of weekly calls to a cessation quitline and the number of weekly registrations to a web-based 

cessation program” (Schillo et al. 2011, p. 1).

Overall, the evidence is sufficient to infer that mass 

media campaigns increase the number of calls to quitlines 

and increase smoking cessation.

State Tobacco Control Programs

CDC’s Office on Smoking and Health created the 

National Tobacco Control Program (NTCP) in 1999 to provide funding and technical support to U.S. state and territorial health departments, with the goal of encouraging 
A Report of the Surgeon General

606 Chapter 7

coordinated, national efforts to reduce tobacco use and 

tobacco-related disease and death. In particular, NTCPfunded state programs seek to achieve the four core goals 

of a comprehensive tobacco control program outlined 

in Best Practices for Comprehensive Tobacco Control 

Programs (or Best Practices): 

• Prevent initiation among youth and young adults,

• Promote quitting among adults and youth,

• Eliminate exposure to secondhand smoke, and 

• Identify and eliminate tobacco-related disparities 

among population groups (CDC 2014a).

To achieve the goal of promoting quitting among 

adults and youth, as well as the other three goals, comprehensive state tobacco control programs should include 

the following components: state and community interventions; mass-reach health communication interventions; 

cessation interventions; surveillance and evaluation; and 

infrastructure, administration, and management (CDC 

2014a). As recommended in CDC’s Best Practices, support for both direct provision of treatment and support 

for health systems and population-based tobacco control 

policies is what contributes to a comprehensive program 

(CDC 2014a), which has the greatest impact on increasing 

quit success.

The Community Preventive Services Task Force 

concluded that, based on the evidence, comprehensive 

tobacco control programs are effective in reducing tobacco 

use and exposure to secondhand smoke (The Community 

Guide 2014). Evidence indicates that such programs 

reduce the prevalence of tobacco use among adults and 

young people, increase the rate of quitting, and contribute 

to reductions in tobacco-related diseases and deaths. The 

Task Force concluded that comprehensive tobacco control programs are cost-effective, with savings from averted 

healthcare costs exceeding the costs of cessation interventions (The Community Guide 2014).

The Task Force reviewed 61 studies (through August 

2014) on the impact of comprehensive tobacco control 

programs (The Community Guide 2014). Fifty-six of the 

studies evaluated the effects of such programs on cigarette 

use. Comprehensive tobacco control programs implemented over a median of 9 years were associated with an 

overall median decrease of 3.9 percentage points (-5.6 to 

-2.6 percentage points in 16 studies) in the prevalence of 

smoking among adults. More specifically, national studies 

showed a median decrease of 2.8 percentage points (-3.5 to 

-2.4 percentage points in 12 studies) in the prevalence of 

smoking among adults.

One of the studies reviewed by the Task Force compared California, a state with a comprehensive tobacco control program, with two states (New Jersey and New York) 

with similar policy climates but without comprehensive 

tobacco control programs from 1992 to 2002. The study 

found that long-term smoking cessation rates among adults 

were significantly higher in California compared with the 

other two states (Messer et  al. 2007). In another study, 

Farrelly and colleagues (2008) examined the association 

between cumulative expenditures for state-specific antitobacco programs and changes in the prevalence of smoking 

among adults from 1985 to 2003. The authors concluded 

that expenditures on state tobacco control programs were 

associated with overall reductions in adult smoking. Rhoads 

(2012) used data from 1991 to 2006 in the Behavioral Risk 

Factor Surveillance System to examine the effects of comprehensive state tobacco control programs on cigarette 

smoking among adults. This study found that state programs had a significant impact on reducing the prevalence 

of cigarette smoking among adults, and that if all states 

had funded comprehensive tobacco control programs at 

the CDC-recommended level every year from 1991 to 2006, 

the prevalence of adult smoking in 2006 would have been 

between 18.5% and 19.8% instead of the observed prevalence of 20.07% (i.e., a 1.4–8.8% change), which translates 

into 635,000–3.7 million fewer cigarette smokers.

Despite the strong evidence base for many components of comprehensive tobacco control programs, the specific effects of state-funded clinical treatment programs for 

smoking cessation are less clear, and these effects appear 

to depend, in part, on sustained funding, availability, and 

promotion of cessation services. For example, two states 

have demonstrated that clinical cessation programs can 

yield high quit rates. New Jersey, with minimal funding, 

demonstrated high quit rates among moderate-to-heavy 

tobacco users who were treated at 15 clinics, worksites, or 

state-funded community cessation centers (Foulds et al. 

2006; University of Medicine & Dentistry of New Jersey 

and School of Public Health 2007). Similarly, Minnesota 

developed QUITPLAN cessation treatment centers that 

operated for approximately 6 years (An et al. 2010). In an 

observational study of cohorts of participants of the service in 2004, 616 adults enrolled in the treatment centers, 

and 2,351 adults contacted the telephone-based helpline. 

Smokers at the treatment centers had a higher level of nicotine dependence than those who used a worksite, phone, 

or web-based treatment program. The 30-day quit rate 

was higher among smokers who contacted the telephonebased helpline (29.3%) than among smokers who attended 

the treatment centers (25.8%) (An et al. 2010). In another 

example, England’s Stop Smoking Services have demonstrated high long-term quit rates with sustained funding 

for clinical treatment (>16 years) (Public Health England 
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 607

Smoking Cessation

2017). Existing evidence suggests that states that sustain 

adequate funding for comprehensive tobacco control programs can achieve higher rates of cessation.

Overall, the evidence is sufficient to infer that comprehensive state tobacco control programs can reduce 

the prevalence of smoking among adults, increase quit 

attempts, and increase smoking cessation. Because state 

tobacco control programs typically involve multiple strategies and components, it is difficult to attribute their 

effects to specific cessation strategies (such as support for 

clinical or onsite cessation services). The final section of 

this chapter describes how simulation studies can be used 

to evaluate the individual and synergistic effects of multiple tobacco control strategies.

Pictorial Health Warnings

Since 1965, Congress has enacted legislation 

requiring cigarette packages in the United States to carry 

small, text-based health warnings. Health warnings on 

cigarette packages can be an important means of conveying information to smokers about the health effects 

of smoking and available cessation resources. Nearly 

50 countries now require large pictorial health warnings 

(also called graphic warning labels), often covering 50% or 

more of the cigarette package, that feature graphic depictions of smoking-related disease and a phone number for 

a tobacco cessation quitline (Hammond 2011; USDHHS 

2014). However, health warnings on cigarette packages 

in the United States are weaker and less prominent than 

health warnings used on packages in many other countries (USDHHS 2000, 2014).

Evidence suggests that large, pictorial health warnings are a more effective means of reaching smokers 

than small, text-based messages (Hammond 2011). 

Furthermore, substantial evidence suggests that large pictorial health warnings that highlight the health risks of 

smoking are associated with increased knowledge of the 

harms of smoking, increased perceptions of risk associated 

with smoking, increased interest in quitting and motivation to quit, increased number of quit attempts, increased 

likelihood of remaining abstinent after a quit attempt, 

and reduced prevalence of smoking (Borland et al. 2009; 

Hammond 2011; USDHHS 2012; NCI and WHO 2016; 

Noar et al. 2016a,b; Reid et al. 2017). Given this evidence, 

the NCI-WHO Monograph 21 concluded that “Large pictorial health warning labels on tobacco packages are effective in increasing smokers’ knowledge, stimulating their 

interest in quitting, and reducing smoking prevalence” 

(NCI and WHO 2016, p. 13).

Noar and colleagues (2016b) conducted a metaanalysis of 37  experimental studies about the effects of 

pictorial health warnings on tobacco packages in 16 countries. The study reported that “relative to text-only warnings, pictorial warnings (1) attracted and held attention 

better, (2) garnered stronger cognitive and emotional reactions, (3) elicited more negative pack attitudes and negative smoking attitudes, and (4) more effectively increased 

intentions to not start smoking and to quit smoking” 

(p. 341). 

In a separate meta-analysis of longitudinal studies, 

Noar and colleagues (2016a) found that pictorial health 

warnings were associated with a 13% relative reduction 

in the prevalence of smoking among adults and with 

increased quit attempts. In another study with a nationally representative sample of Canadians, Azagba and colleagues (2013) assessed the impact of pictorial health 

warnings on smoking and quitting and found that the 

implementation of such warnings nationwide in Canada 

was associated with decreased prevalence of smoking 

(OR  =  0.875; 95%  CI: 0.82–0.93) and increased odds of 

making a quit attempt (OR  =  1.33; 95%  CI: 1.19–1.49). 

In a study of 14 countries that implemented graphic pictorial warnings, CDC (2011) found that the percentage 

of smokers thinking about quitting increased by at least 

25% in 13 of the 14 countries. 

Studies have also found that pictorial health warnings can lead to increased engagement in cessation treatment (Willemsen et al. 2002; International Tobacco Control 

Policy Evaluation Project 2009; Wilson et al. 2010; Noar 

et al. 2016a; Guydish et al. 2018). For example, in an experimental study, Guydish and colleagues (2018) found that 

smokers exposed to pictorial health warnings on their cigarette packages were significantly more likely to engage in 

a cessation group program compared with controls who 

did not receive pictorial warnings on their cigarette packages. Additionally, Australia, Brazil, the Netherlands, New 

Zealand, and the United Kingdom reported significant 

increases in calls to their national quitlines after the telephone numbers for the quitlines were included on pictorial health warnings (Willemsen et al. 2002; Miller et al. 

2009; Hammond 2011, 2012; Noar et al. 2016a). 

In summary, the evidence is sufficient to infer that 

pictorial health warnings increase smokers’ knowledge of 

health harms from smoking, motivation and intention to 

quit, and quit attempts, and decrease the prevalence of 

smoking, particularly when the labels cover at least 50% 

of the cigarette package and identify specific resources 

and contact information for cessation support, such as a 

phone number for a tobacco quitline. 

Although pictorial health warnings have been implemented in numerous countries worldwide as part of recommendations from the WHO Framework Convention on 

Tobacco Control (FCTC), the United States is not a party 

to the FCTC. In the United States, the Family Smoking 
A Report of the Surgeon General

608 Chapter 7

Prevention and Tobacco Control Act of 2009 (or Tobacco 

Control Act) (2009) requires FDA to implement pictorial health warnings on cigarette packages and advertisements. On June 22, 2011, FDA published a final rule 

requiring color graphics depicting the negative health 

consequences of smoking to accompany the nine textual 

warning statements set out in the Tobacco Control Act.

However, several tobacco companies challenged the final 

rule in court, and on August 24, 2012, the U.S. Court of 

Appeals for the District of Columbia Circuit vacated the 

rule on First Amendment grounds and remanded the 

matter to the agency (R.J. Reynolds Tobacco Co., et al. v. 

FDA et al. 2012).

FDA conducted further research on pictorial health 

warnings. A subsequent lawsuit by public health groups 

filed in 2016 resulted in a September 2018 decision by the 

U.S. District Court of Massachusetts that ordered FDA to 

expedite the issuance of a final rule for cigarette health 

warnings, after finding that FDA had unlawfully withheld 

and unreasonably delayed execution of the provision in 

the Tobacco Control Act that requires the implementation 

of such warnings (American Academy of Pediatrics v. FDA 

2018; FDA 2018a). In March 2019, the U.S. District Court 

of Massachusetts ordered FDA to submit the proposed 

rule for publication in the Federal Register by August 15, 

2019, and to submit the final rule for publication in the 

Federal Register by March 25, 2020 (American Academy 

of Pediatrics v. FDA 2019a). 

FDA issued new cigarette health warnings through a 

proposed rule on August 16, 2019 (Federal Register 2019). 

When finalized, the new health warnings on cigarette 

packages and in advertisements would promote greater 

public understanding of the negative health consequences 

of smoking. The 13 proposed warnings, which feature text 

statements and photo-realistic color images of the lesserknown health risks of cigarette smoking, stand to represent the most significant change to cigarette labels in the 

United States in 35 years.

Plain Packaging

Plain packaging requirements standardize the 

appearance of cigarette packages by removing all brand 

imagery; using a standard background color and specific text size, font, and position; and including government-mandated information, such as health warnings 

(Figure 7.3) (USDHHS 2012b). In 2011, Australia became 

the first country to enact plain packaging requirements. 

Since then, some countries have passed similar laws standardizing the packaging of tobacco and/or cigarette products—including France, Ireland, New Zealand, Norway, 

Saudi Arabia, and the United Kingdom—and other 

countries are in the process of implementing such laws 

(Campaign for Tobacco-Free Kids 2019a). These laws are 

often combined with laws about pictorial health warnings.

Plain packaging can have several possible effects, particularly with regard to reducing the appeal of tobacco products (USDHHS 2012b; WHO 2016b). Plain packaging can:

• Make smoking less appealing because plain packages are less attractive and engaging than packages 

with normal branding (USDHHS 2012b; Hughes 

et al. 2016; WHO 2016b);

Figure 7.3 Pictorial warning on cigarette packages in Australia 

Source: Tobacco Labelling Resource Centre (n.d.a,b), with permission.
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Smoking Cessation

• Enhance the effectiveness of health warnings by

increasing their noticeability (Hammond 2010; WHO 

2016b); and

• Reduce false beliefs about the absolute risks of different tobacco products (Hammond 2010; WHO

2016b).

Taken together, the scientific literature indicates

that removing the color and brand imagery from cigarette 

packages reduces the appeal of cigarettes, enhances the 

effectiveness of health warnings, and may reduce the consumption of cigarettes (USDHHS 2012b; NCI and WHO 

2016; WHO 2016b). Evaluation studies indicate that these 

reductions may, in turn, result in increased quit attempts 

and decreased prevalence of smoking (Durkin et al. 2015; 

McNeill et al. 2017).

Plain packaging can further support and enhance 

cessation efforts by removing misleading packaging and 

labeling and reducing false beliefs about the relative 

risks of different brands of cigarettes. The 2012 Surgeon 

General’s report found that plain packaging has the 

potential to reduce false beliefs on the part of youth and 

adults that one cigarette brand is less harmful or easier 

to quit than another (USDHHS 2012b). In addition, plain 

packaging could counteract efforts by tobacco companies to color-code packages as a way to communicate a 

hierarchy of supposed relative harm within brand families (Dewhirst 2018). This activity occurs in countries, 

including the United States, that prohibit the use of unauthorized modified risk descriptors, such as “light,” “mild,” 

or “low tar” (United States v. Philip Morris USA, Inc. 2015; 

Dewhirst 2018). Reducing false beliefs about differences 

in risks between brands and within brand families could 

increase the number of current smokers who quit entirely 

instead of switching to other perceived “less risky” brands 

of cigarettes.

The tobacco industry has filed lawsuits alleging violations of domestic laws and international laws and treaties in response to regulatory proposals to remove brand 

imagery in the United States and in other countries 

(USDHHS 2012b; WHO 2016b). This speaks to the importance of brand imagery in sustaining purchases and, thus, 

tobacco use (Wakefield et al. 2002). Studies have concluded 

that plain packaging requirements can reduce cigarette 

consumption (WHO 2016b); and Australia’s plain packaging requirements, which were implemented in conjunction with requirements around pictorial health warnings, 

have helped to reduce the national prevalence of smoking 

(Chipty 2016; Australian Department of Health n.d.).

The evidence is suggestive, but not sufficient, to 

infer that plain packaging increases smoking cessation 

(Moodie et al. 2011; Mannocci et al. 2013; USDHHS 2014; 

WHO 2014; McNeill et  al. 2017). Although the body of 

evidence on the efficacy of plain packaging continues to 

grow, further evaluation of these policies is required to 

better understand the specific impacts of plain packaging 

requirements on smoking cessation behavior.

Reduced Retail Point-of-Sale 

Advertising and Retail Density

Population-based policies linked to the sale and 

retailing of tobacco products have the potential to increase 

rates of smoking cessation, but the level of evidence is not 

yet sufficient to draw broad conclusions about their impacts 

on cessation behavior. These policies include decreasing 

point-of-sale tobacco marketing or exposure to advertising 

and decreasing the retail availability of tobacco products. 

The 1998 MSA between 46 U.S. states and the four 

largest tobacco companies in the United States requires 

those companies to make payments to the settling states 

in perpetuity to offset medical costs associated with 

smoking. The MSA also restricts the advertising, marketing, and promotional activities of the four companies, 

including the use of cartoons, billboards, or merchandise 

branding to advertise cigarettes (National Association 

of Attorneys General n.d.). Although smoking rates in 

the United States have continued to decline since 1998 

(USDHHS 2014), evidence suggests that the tobacco 

industry has shifted its marketing strategy to focus on the 

retail environment in direct response to the MSA (Ruel 

et al. 2004). Retail stores are now the primary means by 

which the tobacco industry advertises and promotes its 

products. In 2017, the tobacco industry spent more than 

$1 million per hour marketing cigarettes and smokeless 

tobacco, a large majority of which was spent on discounts 

to help retailers reduce the price of tobacco products for 

consumers (Federal Trade Commission 2019a,b). In addition to offering price discounts, the tobacco industry 

advertises its products in the interior and on the exterior 

of retail stores (USDHHS 2012b; Center for Public Health 

Systems Science 2016). 

Several policies that regulate the advertising of 

tobacco products in retail spaces have the potential to 

reduce the affordability, availability, and attractiveness 

of tobacco products (Center for Public Health Systems 

Science 2016) and to help support persons who are trying 

to quit using tobacco (Clattenburg et al. 2013; Mantey et al. 

2017). For example, in addition to increasing smoking initiation among youth (USDHHS 2012b, 2014), the advertising of tobacco products in retail stores may undermine 

cessation attempts among adult smokers by increasing 

their cravings or prompting them to make unplanned 

purchases (McCarville and Bee 1999). The number and 
A Report of the Surgeon General

610 Chapter 7

location of tobacco retail stores (retail density) also can 

influence cessation. Proximity to tobacco retail outlets 

and higher retailer density are associated with reduced 

quit attempts for adults and can foster disparities in 

tobacco use and cessation behaviors (Chuang et al. 2005; 

Henriksen et al. 2008; Center for Public Health Systems 

Science 2014, 2016; Lipperman-Kreda et al. 2014; YoungWolff et al. 2014). 

Regarding exposure to point-of-sale tobacco marketing, in a study of 999  adult smokers in Nebraska, 

Siahpush and colleagues (2016) found that exposure 

to greater amounts of point-of-sale advertising in one’s 

neighborhoods was associated with a lower probability 

of quit success among smokers who reported making a 

quit attempt in the previous 6 months. In a study of adult 

smokers in Australia, Germain and colleagues (2010) 

found a negative association between sensitivity to pointof-sale tobacco marketing and making a quit attempt. 

Some jurisdictions have also restricted the use of coupons and discounts, because evidence clearly shows that 

increasing price is the single most effective policy strategy 

to reduce tobacco use (USDHHS 2000, 2012b). 

Reducing the number of retailers is another policy 

strategy that may reduce tobacco use, given the relationship between tobacco retailer density and tobacco use 

(Institute of Medicine 2007; Luke et  al. 2017). Several 

studies have associated decreased long-term tobacco cessation with the increased availability of tobacco in retail 

markets, after considering retail density (i.e., the number 

of retailers per area or population) and retail proximity 

(i.e., the distance to the nearest retailer from one’s home 

or school). For example, in a study of more than 400 adult 

smokers in Houston, Texas, Reitzel and colleagues (2011) 

found that even after adjusting for several sociodemographic variables, residential proximity to tobacco outlets provided unique information for predicting longterm continuous abstinence from smoking during a 

specific quit attempt. Those living less than 250  meters 

or less than 500 meters from a tobacco outlet were less 

likely to sustain a quit attempt than those living farther 

than 250 or 500 meters (p = 0.01 and p = 0.04, respectively). In the United Kingdom, Han and colleagues (2014) 

could not replicate Reitzel and colleagues’ (2011) findings; however, the location and coding of retail outlets differed between the two studies. In a study of 8,751 adult 

smokers in Finland, Halonen and colleagues (2014) found 

that, among men who were moderate to heavy smokers at 

baseline, those living less than 0.5 kilometers (km) from 

the nearest tobacco store had a 27% lower likelihood of 

cessation at follow-up compared with those living 0.5 km 

or more from such a store, and that having a store within 

0.5  km of one’s home decreased cessation in men who 

were moderate or heavy smokers. 

In summary, 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. 

Although causal conclusions cannot be drawn at this 

time, these findings should not prevent tobacco control 

practitioners from taking action to reduce the retail density of tobacco outlets and the impact of point-of-sale 

tobacco marketing and product offerings and to evaluate 

and report the results of such actions. A strong theoretical basis exists for limiting tobacco retail density, in part, 

because of the causal relationship between tobacco marketing and increased tobacco consumption (NCI 2008). 

Furthermore, evidence from alcohol control research 

indicates that limiting alcohol retail density can reduce 

excessive alcohol consumption (Campbell et al. 2009); this 

relationship may translate to tobacco.

Restricting the Sale of Certain 

Types of Tobacco Products

The 2014 Surgeon General’s report concluded 

that imposing greater restrictions on the sale of certain 

types of tobacco products may also help to accelerate 

the decline of tobacco use (USDHHS 2014), particularly when coupled with other cessation strategies. This 

may include restricting the sale of certain tobacco products (e.g.,  menthol-flavored tobacco products, products 

with other flavors) or restricting the sale of all tobacco 

products in a setting (e.g.,  a pharmacy). The appeal of 

flavored tobacco products to youth and young adults is 

well-documented (USDHHS 2012b, 2016). Congress, 

concerned about tobacco use among youth, enacted the 

Tobacco Control Act of 2009, which banned cigarettes with 

characterizing flavors (e.g., cherry, chocolate, etc.) other 

than menthol (USDHHS 2012a). Menthol is a widely used 

flavor-characterizing additive in cigarettes among all age 

groups (Rose et al. 2019), with approximately 39% of all 

smokers reporting use of menthol cigarettes in 2012–2014 

(Villanti et  al. 2016). Use of menthol cigarettes is more 

prevalent among African Americans, Hispanics, smokers 

of lower socioeconomic status, and women (Delnevo et al. 

2011; Giovino et al. 2015; Rath et al. 2016). 

Menthol has been found to impede tobacco cessation (FDA n.d.; Villanti et al. 2017). In a rigorous review of 

the scientific evidence, FDA’s Tobacco Products Scientific 

Advisory Committee concluded that menthol in cigarettes 

is associated with increased dependence and reduced 

success in smoking cessation, especially among African 

American smokers (Stahre et al. 2010; Hoffman and Miceli 

2011; Levy et al. 2011a; FDA n.d.). Several reviews (Foulds 

et al. 2010; Villanti et al. 2017; FDA n.d.) and randomized 
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Smoking Cessation

controlled trials (Faseru et al. 2013; Rojewski et al. 2014; 

Smith et  al. 2014) have reached the same conclusions. 

Specifically, smokers of menthol cigarettes make more 

quit attempts than smokers of nonmenthol cigarettes but 

have a more difficult time quitting successfully (Trinidad 

et al. 2010; Delnevo et al. 2011; Levy et al. 2011a; Villanti 

et al. 2017). Potential explanations for the negative impact 

of menthol on cessation is that menthol leads to greater 

nicotine exposure and dependence (Benowitz et al. 2004; 

Giovino et al. 2004) or enhances the rewarding effects of 

nicotine (Wickham et al. 2015; Henderson et al. 2017).

However, not all studies have found an association 

between menthol use and cessation (Hyland et al. 2002; 

Fu et al. 2008; Steinberg et al. 2011). Differences in sampled populations, settings, study designs, and control 

variables may account for inconsistencies (Smith et  al. 

2019). Although, a meta-analysis of 19  studies of nearly 

150,000 cigarette smokers did not find a significant association between menthol use and cessation (adjusted 

OR  =  0.95; 95%  CI, 0.89–1.03), it found that Black or 

African American menthol users were significantly less 

likely to quit than their nonmenthol-using counterparts 

(adjusted OR: 0.88, p  <.05) (Smith et  al. 2019). Many 

studies that have not found an association between menthol cigarette use and cessation in the general population 

have found an association by race/ethnicity, with African 

American menthol smokers having a lower likelihood of 

smoking cessation (Lewis et al. 2014; Smith et al. 2019; 

FDA n.d.). Use of menthol cigarettes has been shown to 

contribute to tobacco cessation-related disparities in the 

United States (Gardiner and Clark 2010; Garrett et  al. 

2016; FDA n.d.). Smith and colleagues (2019) concluded 

that menthol bans will have a favorable impact on smoking 

cessation rates among Black or African American smokers.

In 2016, WHO conducted a review of menthol 

in tobacco products and based on the evidence, recommended a ban on menthol in cigarettes, including menthol analogues, precursors, and derivatives (WHO 2016a). 

WHO also recommended prohibiting menthol in products 

other than cigarettes. Several countries have since adopted 

these WHO recommendations (WHO 2016a; 2018). In the 

United States in 2013, the city of Chicago was the first 

U.S. jurisdiction to restrict the sale of menthol tobacco 

products. After local retailers sued the city to block the 

policy, the court found that local governments have the 

authority to restrict the sale of menthol tobacco products 

(Independents Gas & Service Stations Associations, Inc. v. 

City of Chicago 2015; Tobacco Control Legal Consortium 

2018). As of October 2019, more than 50 U.S. municipalities have restricted the sale of menthol tobacco products 

(Campaign for Tobacco-Free Kids 2019b). 

In several studies, menthol smokers reported that 

they would quit smoking if the sale of menthol cigarettes 

was prohibited (Tobacco Products Scientific Advisory 

Committee 2011; Pearson et  al. 2012; Wackowski et  al. 

2014, 2018; Zatonski et al. 2018; Rose et al. 2019; FDA n.d.), 

but cessation and health impacts could be diminished if 

other types of menthol-flavored tobacco products were 

still available (Wackowski et  al. 2015; Pacek et  al. 2019; 

Rose et al. 2019). For example, initial evaluations of quit 

behaviors and restrictions on the sales of menthol tobacco 

products in Ontario, Canada, suggested that such restrictions may impact cessation (Chaiton et al. 2018a,b; 2019a). 

Another study that evaluated the long-term, populationlevel impact of the menthol restriction in Ontario showed 

that during the first year of implementation, a significantly 

higher percentage of persons who smoked menthol cigarettes quit smoking than those who smoked nonmenthol 

cigarettes and quit that same year (Chaiton et al. 2019b). 

Less is known about the potential impacts that 

broader flavor bans could have on cessation. However, the 

role of flavors in promoting initiation of tobacco product 

use among youth is well established. Youth are more likely 

than adults to initiate tobacco product use with flavored 

tobacco products (Villanti et al. 2017, 2019), and appealing 

flavor is cited by youth as one of the main reasons for using 

e-cigarettes (USDHHS 2016; Villanti et al. 2017). Moreover, 

longitudinal analyses of data from the PATH Study show 

that first use of a flavored tobacco product is associated 

with an increased likelihood of subsequently using tobacco 

products (flavored or unflavored) compared with those who 

initiate tobacco use with an unflavored tobacco product 

(Villanti et al. 2019). Given the role of flavors in promoting 

tobacco product initiation among youth, more than 

220 U.S. municipalities have restricted the sale of flavored 

tobacco products, including e-cigarettes, and several states 

have adopted partial restrictions on the sale of flavored 

tobacco products, including those that passed emergency 

rules in 2019 to restrict the sale of flavored e-cigarettes 

(Campaign for Tobacco Free Kids 2019b; Public Health 

Law Center 2019). Most studies to date about restrictions 

on the sale of flavored tobacco products have focused on 

the impact of restrictions on sales, product availability, and 

use by youth (Courtemanche et al. 2017 ; Farley and Johns 

2017; Rogers et al. 2017, 2019; Brock et al. 2019; Czaplicki 

et al. 2019; Kingsley et al. 2019). More research is needed 

to understand the impacts that these types of policies have 

on cessation behaviors, and the implementation of such 

policies should be accompanied by a comprehensive cessation approach that seeks to make available and promote 

evidence-based cessation treatment.

Policies restricting the sale of certain tobacco products may extend beyond flavors and encompass restrictions 

on the sale of all tobacco products in certain retail settings. 

A limited amount of evidence exists on the impacts that 

these policies may have on cessation, and their impact 
A Report of the Surgeon General

612 Chapter 7

likely depends on the level of evidence-based cessation 

support made available to smokers in conjunction with 

enacting such policies. For example, in September 2014, 

CVS Health stopped selling tobacco products in its pharmacies and launched a comprehensive program to support 

smokers in their efforts to quit, including smoking cessation counseling offered through healthcare providers and 

retail pharmacists, promotion of NRT products, a dedicated 

quitline, and other resources (Brennan et al. 2014). Nearly 

1  year after the policy change, an evaluation found that 

in states in which the intervention was implemented, the 

average smoker purchased five fewer packs of cigarettes 

each month compared with three control states with no 

CVS stores (Polinski et al. 2015). Moreover, smokers who 

had purchased cigarettes exclusively at CVS were 38% more 

likely to stop buying them (Polinski et al. 2017). Cessation 

and quitting outcomes were not directly assessed.

Overall, the evidence is suggestive, but not sufficient, to infer that restricting the sale of certain types of 

tobacco products, such as menthol and flavored products, 

increases smoking cessation. Rigorous evaluation of policies addressing this topic in the United States and abroad 

would be useful to better understand the effects that such 

policies have on tobacco cessation.

Very-Low-Nicotine-Content 

Cigarettes

Benowitz and Henningfield (1994) first proposed 

the idea of systematically reducing the levels of nicotine 

content in cigarettes as a way to prevent the development 

of nicotine addiction in youth. However, the authors noted 

that this strategy might also increase the likelihood that 

addicted (adult) smokers would stop smoking, because 

as the nicotine in cigarettes was lowered to nonaddictive 

levels, they would become less reinforcing and less satisfying. The authors estimated that, to avert addiction, daily 

intake of nicotine should be limited to 5  milligrams or 

less. Assuming a 30-cigarette-per-day smoker, this translates to less than 0.5 milligrams of nicotine per cigarette. 

Thus, very-low-nicotine-content cigarettes could achieve 

the dual goals of promoting cessation and preventing 

smoking initiation.

Since that time, several studies have tested the effects 

of experimental very-low-nicotine-content cigarettes on 

key relevant outcomes, and have suggested that such 

products may reduce smoking and dependence, increase 

abstinence, and reduce exposure to toxicants (Benowitz 

et al. 2007, 2012; Donny et al. 2007, 2014, 2015; Donny 

and Jones 2009; Hatsukami et  al. 2013; Dermody et  al. 

2018). This approach was noted as one of several potential “end game” strategies in the 2014 Surgeon General’s 

report (USDHHS 2014). Furthermore, the growing body of 

evidence (see Chapter 6 for a full review) has led to recent 

regulatory actions. 

Although the Tobacco Control Act (2009) bars FDA 

from requiring nicotine yields of a tobacco product to be 

reduced to zero, it allows FDA to promulgate regulations 

regarding the construction; components; ingredients; 

additives; constituents, including smoke constituents; 

and properties of tobacco products if such regulations 

are appropriate for the protection of the public health. In 

July 2017, Dr. Scott Gottlieb, then Commissioner of FDA, 

announced “a new comprehensive plan for tobacco and 

nicotine regulation that will serve as a multi-year roadmap 

to better protect kids and significantly reduce tobaccorelated disease and death. The approach places nicotine, 

and the issue of addiction, at the center of the agency’s 

tobacco regulation efforts” (FDA 2017). With that policy 

proposal, FDA had planned to “begin a public dialogue 

about lowering nicotine levels in combustible cigarettes to 

nonaddictive levels through achievable product standards” 

(FDA 2017). In 2018, the agency issued an Advance Notice 

of Proposed Rulemaking to seek input on the potential 

public health benefits and any possible adverse effects of 

lowering the level of nicotine in cigarettes (FDA 2018c). As 

outlined in the evidence review in Chapter 6 of this report, 

such regulatory action could reduce nicotine dependence 

and increase tobacco abstinence. No country, to date, has 

implemented such a policy around cigarettes. 

E-Cigarettes

The scientific evidence surrounding e-cigarettes 

and cessation occurs within a broader environmental context with important policy and regulatory considerations. 

E-cigarette use has increased considerably among U.S. 

youth since 2011, with the U.S. Surgeon General declaring 

it an epidemic in 2018 (Office of the U.S. Surgeon General 

n.d.). By contrast, based on currently available evidence, 

e-cigarettes could benefit adult smokers if the products are 

used as a complete substitute for conventional cigarettes 

(see Chapter 6). However, the health effects of e-cigarettes 

to date remain uncertain. Furthermore, CDC, FDA, state 

and local health departments, and public health and clinical partners have been investigating a multistate outbreak of lung injury associated with the use of e-cigarette, 

or vaping, products since August 2019. The latest national 

and state findings suggest e-cigarette, or vaping, products containing tetrahydrocannabinol (or THC), particularly those obtained off the street or from other informal 

sources (e.g.,  friends, family members, illicit dealers), 

are linked to most of the cases and play a major role in 

the outbreak (Siegel et al. 2019). Federal, state, and local 
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 613

Smoking Cessation

governments have implemented, or are considering, regulations and other policy activities related to e-cigarettes in 

an effort to respond to this outbreak.

In the United States, e-cigarettes can be regulated 

as either tobacco products or, when marketed for therapeutic purposes, as medical products (Federal Register 

2016). The Tobacco Control Act defines the term “tobacco 

product,” in part, as any product, “made or derived from 

tobacco,” including component, parts or accessories of a 

tobacco product that is not a “drug,” “device,” or “combination product” as defined by the Food, Drug, and Cosmetic 

Act (21 U.S.C. 321 (rr)) (Family Smoking Prevention and 

Tobacco Control Act 2009, §101(a)). In 2010, the U.S. 

Court of Appeals for the D.C. Circuit held that FDA has the 

authority to regulate customarily marketed tobacco products under the Tobacco Control Act and products made or 

derived from tobacco that are marketed for a therapeutic 

purpose under the medical product provisions of the Food, 

Drug, and Cosmetic Act (Sottera, Inc.  v. Food & Drug 

Administration 2010). 

The Center for Tobacco Products (CTP) issued a 

final rule (the “deeming rule”) in May 2016 extending the 

FDA’s authority to regulate tobacco products to all products meeting the definition of a “tobacco product” under 

the Food, Drug, and Cosmetic Act, except accessories of 

tobacco products. Therefore, all newly deemed tobacco 

products, including e-cigarettes must undergo premarket 

review and authorization by FDA (FDA 2016). In July 2017, 

FDA extended the compliance period for premarket applications to August 2022 for electronic nicotine delivery systems (or ENDS) and removed the “sunset policy,” whereby 

FDA deferred enforcement for products on the market 

while their application is reviewed. A lawsuit filed by 

American Academy of Pediatrics (AAP) and other public 

health groups challenged this compliance period. On 

July 12, 2019, the court issued the final order in the AAP 

case as follows: Premarket applications must be submitted 

within 10 months of the order (May 12, 2020) for deemed 

products on the market as of the Deeming Rule (August 8, 

2016). Deemed products that submit an application by 

the deadline might remain on the market for up to 1 year 

while FDA reviews the application and then would be 

required to come off the market (sunset provision) if the 

products have not yet received a marketing authorization 

(American Academy of Pediatrics v. FDA 2019b).

The statutory standards for tobacco products differ 

from those applied to FDA-approved NRTs, which are 

approved by the Center for Drug Evaluation and Research 

(CDER). For example, CDER requires evidence for the 

safety and efficacy of drugs, including cessation medications, generally coming from randomized controlled 

trials. By contrast, CTP employs a public health standard, 

which considers risks and benefits to users and nonusers 

of tobacco products and the population effects, for evaluating the evidence base to support commercial marketing 

of tobacco products. Regarding the potential for regulation of an e-cigarette product as a tobacco product, on 

October  11, 2019, one tobacco company announced the 

submission of a Premarket Tobacco Product Application 

(PMTA) to the FDA seeking orders authorizing the marketing of an ENDS product (Reynolds American 2019). 

E-cigarettes currently on the market that meet the definition of tobacco product under the federal Food, Drug, and

Cosmetic Act are classified as tobacco products.

Under the Tobacco Control Act, states, localities, 

territories, and tribes maintain broad authority to adopt 

additional or more stringent requirements regarding 

tobacco product use, sales, marketing, and other topics. 

Accordingly, several states have enacted laws related to 

e-cigarettes in recent years, primarily to reduce youth

initiation and use (Marynak et al. 2017). State, local, and

territorial strategies to reduce initiation of e-cigarettes

among youth and population-level exposure to e-cigarette

aerosol, including educational initiatives, coupled with

federal regulations around tobacco product manufacturing, labeling, and marketing, could help to reduce the

risks of e-cigarettes on population health, especially among 

young persons (USDHHS 2016; Office of the U.S. Surgeon

General n.d.). However, the extent to which populationbased policies focused on e-cigarettes impact adult use of

e-cigarettes or conventional cigarettes, including cessation behaviors, is unknown.

Modeling to Assess the Impact of Policy and Regulatory Changes 

on Cessation

As part of empirical policy evaluations, statistical 

analyses can generally identify the effects of a single 

strategy or group of strategies over a time period soon after 

the strategies are implemented. Simulation modeling, an 

alternative approach, generally synthesizes information 

from empirical strategy evaluations and other sources 

to predict the long-term effects of a policy or a combination of strategies. In the context of tobacco use and 

cessation, simulation modeling estimates the individual 

and combined effects of strategies on such outcomes as 
A Report of the Surgeon General

614 Chapter 7

quit attempts, smoking prevalence, smoking-attributable 

deaths, and other health variables.

Most policy-oriented simulation models used for the 

United States have focused on the effects of implementing 

stronger tobacco control strategies, either individually or 

in combination, on the prevalence of future smoking and 

cessation (NCI 2007; USDHHS 2014). This section focuses 

on simulation models that examine the effects of strategies that are relevant to tobacco cessation in the United 

States. The Appendix to Chapter 15 of the 2014 Surgeon 

General’s report (USDHHS 2014) offers an in-depth summary of tobacco control simulation models.

The most widely modeled policies are tax- and pricerelated strategies (USDHHS 2014). The SimSmoke model 

is a commonly used model. It utilizes a discrete Markov 

model that projects smoking prevalence and smokingattributable deaths in the absence of policy change, and 

then estimates the effect of tobacco control policies on 

those outcomes; the policy effects are based on published 

reviews of the literature and the advice of an expert panel. 

The model has been described extensively in the scientific 

literature, as well as in previous U.S. Surgeon General’s 

reports, and has been shown to predict well at the 

national and state levels (Levy et al. 2000; USDHHS 2014). 

The SimSmoke model (Levy et  al. 2000) predicts that a 

$1.00 tax increase applied to an initial price of $2.00 would 

yield a 13% reduction in the prevalence of cigarette 

smoking among adults after 5  years (short-term) and a 

30% reduction after 40 years. Other models have projected 

similar reductions in smoking prevalence associated with 

comparable tax increases (Emery et al. 2001; Kaplan et al. 

2001; Ahmad 2005; Ahmad and Franz 2008), and one study 

of Latino smokers in California predicted a larger effect 

(Emery et al. 2001). A review of tax simulations found a 

linear relationship between the dollar amount of the tax 

and the relative reduction in the prevalence of smoking 

through both a reduction in initiation and an increase in 

cessation (Feirman et al. 2017). The decrease in smoking 

prevalence attributable to a tax on cigarettes ranged from 

8% (from a $0.71 tax) to 46% (from a $4.63 tax).

In analyses that focused on the use of cessation treatments rather than on taxes or price, Apelberg and colleagues (2010) estimated that there would be 40,000 fewer 

smoking-attributable deaths in the United States with 

a gradual increase in the proportion of NRT-aided quit 

attempts to 100% by 2025, and the BENESCO (Benefits 

of Smoking Cessation on Outcomes) model projected that 

the provision of bupropion and varenicline to a hypothetical cohort of U.S. adult smokers, who made a one-time 

quit attempt, would increase the cessation rate from 5% 

(unaided) to about 15% and 22%, respectively, and the provision would be cost-effective (Howard et al. 2008; Knight 

et al. 2010). Importantly, some of the assumptions in both of 

these models, especially assumptions related to the utilization of medications, were based on data from clinical trials 

and are unlikely to correspond to findings on the effectiveness of medications outside of a clinical trial setting.

In contrast to these studies, which focused on policies involving specific cessation treatments, the SimSmoke 

model considers a set of more comprehensive government 

cessation policies, including expansion of cessation treatment coverage and provider reimbursement; adequate 

funding for the use and promotion of evidence-based 

state quitlines; and support for health system changes to 

prompt, guide, and incentivize tobacco treatment (Abrams 

et al. 2010; Levy et al. 2010) (Figure 7.4). The SimSmoke 

model projected that, if these evidence-based policies for 

cessation were undertaken in 2008, the prevalence of cigarette smoking would be reduced from 20.1% in 2008 to 

9.7% in 2020 (a 10.4-percentage-point change) (Levy et al. 

2010). Finally, Ong and Glantz (2005) estimated that a free 

NRT program could reduce the prevalence of smoking by 

20% among smokers in Minnesota.

Simulation models have also been used to consider 

the impact of smokefree air laws and mass media campaigns on smoking and smoking cessation behaviors. The 

SimSmoke model projected that implementing comprehensive smokefree laws would reduce the prevalence of 

cigarette smoking by 10% in the short term and 13% in 

the long term (Levy and Friend 2001), and Ong and Glantz 

(2005) estimated that 14.7% of current smokers would 

quit smoking if all U.S. indoor workplaces went smokefree. The SimSmoke model has predicted that large-scale 

mass media campaigns can reduce the prevalence of 

smoking by 6% in the short term and 10% in the long 

term (Levy and Friend 2001). Elsewhere, Rivara and colleagues (2004) estimated that a hypothetical multimedia 

campaign implemented for a cohort of 18-year-olds in the 

year 2000 would produce a 9% decrease in the prevalence 

of smoking in this cohort by 2067.

In an assessment of the historical impacts of combined strategies, a SimSmoke model for the United States 

attributed a 53% reduction in the prevalence of cigarette 

smoking by adults to strategies that were implemented 

between 1964 and 2012 (Levy et al. 2016). In terms of relative reductions in the prevalence of smoking for states with 

relatively comprehensive cessation strategies, SimSmoke 

models predicted a 25% reduction from strategies implemented in California between 1988 and 2003 (Levy et al. 

2007a), a 20% reduction from strategies implemented in 

Arizona between 1993 and 2002 (Levy et al. 2007b), and a 

29% reduction from strategies implemented in Minnesota 

between 1993 and 2011 (Levy et al. 2012). All of these 

models were validated against actual rates of smoking by 

age and sex during the time periods considered and were 

found to have high predictability.
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 615

Smoking Cessation

The aforementioned simulation models focused on 

strategies that directly affect cigarette use by individual 

smokers, but other simulation models have examined the 

effects of strategies at the population level. For example, in 

a recent modeling study, Apelberg and colleagues (2018) 

assessed the impact that reducing the nicotine content 

in cigarettes to minimally addictive levels would have 

on smoking cessation. The study predicted that approximately 5 million additional smokers would quit smoking 

within 1 year after implementing such a strategy and that 

this number would increase to 13 million within 5 years. 

The model accounted for dual use and switching behaviors 

by assuming that certain other combustible and noncombustible tobacco products (e.g., premium cigars, hookah, 

e-cigarettes), which might serve as substitutes for conventional cigarettes, would be excluded from the hypothetical 

nicotine reduction strategy. An older model of the potential impact of reducing the nicotine content in cigarettes 

projected a 75% reduction in the prevalence of smoking 

among adults over the long term (Tengs et  al. 2005). 

Another model, which estimated the impact over time of 

a ban on menthol cigarettes, predicted a 4–8% reduction 

in the prevalence of smoking among adults in the short 

term and a 5–10% reduction in the long term; percentage 

reductions were larger among African Americans (Levy 

et al. 2011b).

The Tobacco Control Act (2009) provides a regulatory framework in which companies may introduce and 

market tobacco products with lower exposure or risk 

claims, but only after such products have been reviewed 

and their marketing authorized by FDA. These products are classified as modified risk tobacco products 

(MRTPs) (i.e.,  products “sold or distributed for use to 

reduce harm or the risk of tobacco-related disease associated with commercially marketed tobacco products” 

[Family Smoking Prevention and Tobacco Control Act 

of 2009, p. 1812]). Products such as heated tobacco products, snus, and e-cigarettes may have the potential to 

reduce the individual- and population-level harms associated with tobacco use, and several companies have 

submitted applications to FDA seeking authorization to 

market specific products as MRTPs (Murphy et al. 2017). 

On October 22, 2019, FDA (2019) granted the first-ever 

modified risk orders to Swedish Match USA, Inc., for eight 

snus smokeless tobacco products sold under the “General” 

brand name.

Several models have assessed the projected 

population-level impact of potential reduced-harm products relative to cigarettes (Bachand and Sulsky 2013; 

Vugrin et  al. 2015; Weitkunat et  al. 2015), including 

e-cigarettes (Cobb et  al. 2015; Kalkhoran and Glantz 

2015; Cherng et al. 2016; Levy et al. 2017b) and smokeless 

Figure 7.4 Effects of individual and combined policies on the prevalence of smoking among men and women 

18 years of age and older, using the SimSmoke Model 

Notes: Model is described in Levy and colleagues (2010). The authors examined three evidence-based treatment policies related to 

cessation: (1) expand cessation treatment coverage and provider reimbursement; (2) mandate adequate funding for the use and 

promotion of evidence-based, state-sponsored tobacco quitlines; and (3) support healthcare system changes to prompt, guide, and 

incentivize tobacco treatment.
A Report of the Surgeon General

616 Chapter 7

tobacco (Near et al. 2014). These models vary in structure, 

population focus, and modeling methods.

Three simulation models estimated the population 

health impact after introduction of a potentially reducedharm product that is associated with lower health risks 

than cigarettes. Bachand and Sulsky (2013) estimated 

changes in all-cause mortality when potential or actual 

cigarette smokers substitute some or all of their cigarettes 

with a potentially reduced-harm product. The study concluded that partial or complete substitution of cigarettes 

with a lower risk product should provide some overall 

health benefit at the individual level. Vugrin and colleagues 

(2015) provided a range of scenarios using a multiple 

product model that included product switching and dual 

use. The authors found a potential population-level benefit if cigarette smokers switched to a lower risk product, 

but the benefit could be offset over time through increased 

initiation of the new product. Another model, developed 

by researchers at Philip Morris International, estimated a 

hypothetical reduction in smoking-attributable deaths in 

a 20-year period following the introduction of a reducedharm product (Weitkunat et  al. 2015). This model suggests a reduction of approximately 935,000  smokingattributable deaths if cigarette smoking were to completely 

disappear. If a reduced-harm product completely replaced 

cigarette smoking, there would be an expected decrease of 

516,944–780,433 deaths, provided a new, similarly harmful 

alternative was not introduced. Near and colleagues (2014) 

examined the effects of tobacco control strategies on the 

prevalence of cigarette smoking, use of smokeless tobacco 

(snus), and premature mortality in Sweden. The authors 

adapted the SimSmoke model with data from Sweden 

and found that significant reductions in the prevalence of 

smoking, use of snus, and premature mortality could be 

achieved through tax increases, especially when combined 

with other strategies. The prevalence of smoking could 

decrease by as much as 26% in the first few years, reaching 

a 37% reduction within 30 years. 

Several models have estimated the impact of 

e-cigarettes on population health. However, results can 

vary greatly depending on parameter inputs, underlying 

assumptions, and other factors. Cobb and colleagues 

(2015) demonstrated a limited impact on patterns of current and former cigarette use. The model also projected 

that prevalence of e-cigarette use and dual use would be 

low (1% at Years 1 and 5 and 2% at Year 10). According 

to the authors, this limited transition between e-cigarette, 

dual, and former use suggests that this model may have 

been based on insufficient data or that it may have been 

too early to draw inferences regarding the public health 

impact of e-cigarettes. Kalkhoran and Glantz (2015) estimated a wide range of population health effects from the 

increased promotion and use of e-cigarettes. Population 

health benefits are found in scenarios where (1) the use 

of e-cigarettes increases only among smokers who are 

interested in quitting, (2) there is no increased initiation 

of e-cigarette use among nonsmokers, and (3) e-cigarettes 

are used only by youth who would otherwise have smoked 

conventional cigarettes. However, net population harms 

were predicted in scenarios where (1) e-cigarette promotion leads to the renormalization of cigarette smoking and 

(2)  e-cigarettes are used primarily by youth who never 

would have smoked. Cherng and colleagues (2016) concluded that e-cigarettes could have a greater effect on 

smoking cessation than on smoking initiation. However, 

the rapid increase in e-cigarette use among youth in recent 

years and the substantial proportion of youth and young 

adults who use e-cigarettes but never smoked conventional cigarettes (Mirbolouk et al. 2018) suggest that this 

conclusion may need to be re-evaluated. The study also 

suggested that if the use of e-cigarettes led to smoking initiation in never smokers, even small increases in smoking 

cessation due to the use of e-cigarettes could counteract 

any potential impact on the prevalence of smoking. The 

study also found that if e-cigarettes decreased smoking 

cessation by allowing current dual users to continue to 

smoke cigarettes, then the prevalence of smoking at the 

population level could increase considerably. 

More recently, using a Mendez-Warner modeling approach, the National Academies of Sciences, 

Engineering, and Medicine (2018) found that the use of 

e-cigarettes will generate a net public health benefit, at 

least in the short term. The model found that the harms 

from increased initiation by youth will take time to manifest, occurring decades after the benefits of increased cessation are observed. However, for long-term projections, 

the net public health benefit was projected to be substantially less and was negative under some scenarios in the 

model. Importantly, irrespective of the range of assumptions used, the model projected a net public health harm 

in the short and long terms if the products do not increase 

net combustible tobacco cessation in adults. Warner 

and Mendez (2019) used a similar approach, concluding 

that potential life-years gained as a result of e-cigaretteinduced smoking cessation would exceed potential lifeyears lost due to e-cigarette-induced smoking initiation, 

and that these results would hold over a wide range of 

assessed parameters. In contrast, Soneji and colleagues 

(2018), using a Monte Carlo simulation model, found 

that 2,070  additional current cigarette smoking adults 

(25–69  years of age) (95%  CI, -42,900–46,200) would, 

because of e-cigarette use in 2014, quit smoking in 2015 

and remain continually abstinent from smoking for 7 or 

more years. The model also estimated 168,000  additional never-cigarette smoking adolescents (12–17  years 

of age) and young adults (18–29  years of age) (95%  CI, 
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 617

Smoking Cessation

114,000–229,000) would, because of e-cigarette use in 

2014, initiate cigarette smoking in 2015 and become daily 

cigarette smokers at 35–39  years of age. Based on the 

existing scientific evidence related to e-cigarettes and optimistic assumptions about the relative harm of e-cigarette 

use compared with cigarette smoking, the authors concluded that e-cigarette use currently represents more 

population-level harm than benefit. 

Overall, simulation models generally indicate greater 

effects of individual strategies as the effects fully unfold 

over time. The models also indicate that comprehensive, 

multicomponent, evidence-based tobacco control strategies have the potential to yield substantial reductions in 

the prevalence of smoking. Such reductions are driven 

more by increases in smoking cessation than by reduced 

smoking initiation, but models are subject to some limitations (Levy et al. 2001). Simulation models are useful and 

can often be the most reliable sources for estimating longterm effects of interventions, but the projections are only 

as valid as their underlying assumptions and their input 

and transitional probability parameters, which are generally based on available data and sensitivity analysis (see 

Appendix 15.1 in USDHHS 2014). More research is warranted to assess the effects of strategies on specific cessation behaviors and to distinguish between their effects on 

quit attempts, successful quitting, and relapse.

Limitations and Methodologic Gaps

Despite considerable evidence about the effects of 

certain strategies (e.g., media campaigns, price increases, 

and smokefree policies) on the population-wide prevalence 

of cigarette smoking and cessation, the available evidence 

for some strategies is not adequate to reach conclusions 

about the extent to which they influence quit attempts and 

successful quitting. Some analyses can generate estimates 

of the effects of certain policies on these and other specific 

outcomes, but for many policies, this evidence is limited. 

For example, some healthcare strategies (e.g., modifying 

EHRs and adopting EHR-based referral systems) have 

been shown to improve the identification of smokers and 

the delivery of tobacco use and dependence treatment, but 

there is less evidence on the degree to which they directly 

influence quit attempts and successful quitting.

In theory, both healthcare- or clinically oriented 

tobacco use and dependence treatment strategies and 

population-based tobacco control strategies should influence successful cessation, and thus ultimately improve 

health and reduce healthcare costs. Although it is well 

documented that any strategy that reduces the prevalence of smoking by a meaningful amount will improve 

health and thus reduce cost, specific information on strategies’ effects on those outcomes would be beneficial. For 

example, strategies may differ in their relative effects on 

increasing successful quitting versus reducing smoking 

initiation, and such differences would affect how soon 

effects on health outcomes and health-related costs would 

be expected to occur.

The effects of population-based strategies on rates of 

cessation reflect many factors, such as the types of effects 

the strategy produces (e.g.,  effects on initiation vs. cessation), the time lag between the strategy’s implementation and its effects, and the maintenance or duration of its 

effects (e.g., the elasticity between the price of cigarettes 

and cigarette consumption appears to change over time 

[NCI and WHO 2016]). Thus, although some evidence 

is available on the effects of certain policies on certain 

health outcomes (e.g.,  the effects of smokefree policies 

on the occurrence of coronary events [Meyers et al. 2009; 

Hahn 2010; Institute of Medicine 2010; Mackay et al. 2010; 

USDHHS 2014]), the scarcity of data on some potential 

outcomes of specific policies has made comprehensive 

evaluation strategies challenging.

A further limitation to better understanding the 

effects of policies—particularly population-level strategies—on tobacco cessation is the challenge of isolating 

the effects of a particular strategy from those of other past 

or current strategies. The attempt to identify the contribution of a specific strategy to an outcome is complicated 

by the fact that these strategies are rarely implemented in 

isolation. Specifically, the joint effects of new strategies 

may involve additive or interactive effects among similar 

or apparently dissimilar strategies at the federal, state, 

and local levels. A similar complexity is often encountered in analyzing strategies surrounding healthcare 

policies because healthcare systems often adopt a suite 

of tobacco-related strategies at the same time (Papadakis 

et al. 2010).

Progress is being made in addressing these analytic challenges, in part by taking advantage of the greater 

availability of relevant data and methodologic advances. 

For example, in the area of econometrics, the availability 

of improved longitudinal data for such key variables as 

income, cigarette consumption, cessation, tax avoidance, 

and tobacco price makes some analytic approaches more 

feasible (e.g., advanced time series analyses). Progress is 

aided by the greater availability of higher quality data, longitudinal data, and more comprehensive data (e.g.,  data 

that include measures of key covariates). In addition, 
A Report of the Surgeon General

618 Chapter 7

uniform approaches to data collection are increasingly 

being used across different sampling units, such as 

states and nations (International Tobacco Control Policy 

Evaluation Project 2017; WHO n.d.). The greater availability of uniform data across states and countries permits 

more powerful pooled analyses, which have the potential 

to permit statistical control of unmeasured factors that 

might otherwise bias results.

The greater availability of data and methodological 

advances could enhance the ability to accurately estimate 

the effects of different policies on tobacco use and cessation. Still, heightened focus on the effects of certain policies is needed because of their potential impacts on public 

health. These include policies applying to the use of cigarettes and noncigarette tobacco products and strategies 

addressing populations that have limited access to cessation interventions (e.g., the rural poor, psychiatric populations, low-income and unemployed persons, homeless 

populations, and individuals who are incarcerated). More 

research is also needed on the effects of the mechanisms 

through which policies ultimately influence outcomes for 

smoking cessation; on the interactive effects of strategies 

used to implement various policies; and on how strategies 

that are carried out to implement certain policies affect 

the use of nontraditional resources for promoting cessation (e.g., cessation apps, social media).

Summary of the Evidence

Strategies at the clinical, system, and population 

levels can influence the behavior of smokers in ways that 

increase their likelihood of attempting to quit smoking 

and/or of successful smoking cessation.

At the clinical level, important milestones in the evolution of a health systems approach to increasing tobacco 

cessation include the relevant recommendations and 

clinical guidelines issued by The Community Preventive 

Services Task Force, notably its recommendations on provider reminder systems (Hopkins et al. 2001), the recommendations in the Clinical Practice Guideline (Fiore et al. 

2008), and the guidelines issued by USPSTF (2015).

At the systems level, a growing body of research has 

documented the effectiveness of a health systems approach 

in increasing tobacco screening and cessation interventions and in increasing cessation and reducing smoking 

rates at the health system and/or population level. Several 

studies have taken this a step further, reporting reductions 

in primary care office visits for and healthcare-related 

costs from smoking-related diseases (Land et  al. 2012; 

Moody-Thomas et al. 2015).

At the population level, several evidence-based 

tobacco control strategies—including tobacco quitlines; 

policies that raise the price of tobacco; smokefree policies; government-funded mass media and public education campaigns; pictorial health warnings; and adequately 

funded, sustained, comprehensive state tobacco control 

programs—have been shown to reduce the prevalence 

of smoking among adults by increasing quit attempts 

and successful quitting. Although additional strategies—

including those focused on retail density, point-of-sale 

tobacco advertising, and very-low-nicotine-content cigarettes—have been associated with reductions in the prevalence of smoking, more research could further clarify the 

impact of these policies on cessation behavior.

Overall, a landscape that combines both clinical 

and treatment-oriented strategies, as well as systems- and 

population-level strategy changes, is likely to create the 

most supportive environment for quit attempts and successful cessation. The clinical strategies and interventions 

described here and in Chapter 6 focus primarily on behaviors at the individual level, and such behaviors become 

more routine and consistent when strategies and systems 

are put in place that reinforce the delivery of clinical cessation interventions. The systems- and population-level 

strategies described in this chapter have a broad impact, 

can change the context and environment to make it easier 

for individuals to quit, and are more likely to be effective 

in helping people quit and stay quit when coupled with 

individual-level clinical interventions. Accordingly, clinicians and public health practitioners should seek to 

better bridge clinical work with population-based policy 

approaches to maximize tobacco cessation and reduce the 

overall prevalence of tobacco use.
Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation 619

Smoking Cessation

Conclusions

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

practice guidelines increase the delivery of clinical 

interventions for smoking cessation.

2. The evidence is sufficient to infer that with adequate 

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

availability and utilization of treatment services for 

smoking cessation.

3. The evidence is sufficient to infer that strategies that 

link smoking cessation-related quality measures 

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

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

to motivate quit attempts and increase smoking 

cessation.

5. The evidence is suggestive but not sufficient to infer 

that electronic health record technology increases 

the rate of delivery of smoking cessation treatments.

6. The evidence is sufficient to infer that increasing 

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

smoking cessation.

7. The evidence is sufficient to infer that smokefree 

policies reduce smoking prevalence, reduce cigarette 

consumption, and increase smoking cessation.

8. The evidence is sufficient to infer that mass media 

campaigns increase the number of calls to quitlines 

and increase smoking cessation.

9. The evidence is sufficient to infer that comprehensive state tobacco control programs reduce smoking 

prevalence, increase quit attempts, and increase 

smoking cessation.

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

health warnings increase smokers’ knowledge about 

the health harms of smoking, interest in quitting, 

and quit attempts and decrease smoking prevalence.

11. The evidence is suggestive but not sufficient to infer 

that plain packaging increases smoking cessation.

12. The evidence is suggestive but not sufficient to infer 

that decreasing the retail availability of tobacco 

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

13. The evidence is suggestive but not sufficient to infer 

that restricting the sale of certain types of tobacco 

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

certain populations.
A Report of the Surgeon General

620 Chapter 7

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