641

Chapter 8

A Vision for the Future

Introduction 643

Past: Historical Perspective 643

Present: Health Benefits of Cessation 649

Future: Ending the Tobacco Use Epidemic 651

Progress and Challenges 651

End-Game Strategies 653

Advancing Cessation 656

Accelerating National Momentum to Promote Cessation 658

References 661

A Vision for the Future 643

Smoking Cessation

Introduction

The progress made in reducing cigarette smoking 

in the United States over the past five decades represents 

one of the most notable public health achievements of the 

past century (Ward and Warren 2007; U.S. Department 

of Health and Human Services [USDHHS] 2014). Since 

the first Surgeon General’s report on smoking and health 

was released in 1964, current cigarette smoking among 

U.S. adults 18 years of age and older has declined from 

42.6% in 1964 to a low of 14.0% in 2017 (Wang et  al. 

2018). This decline has brought within reach USDHHS’ 

national Healthy People 2020 goal of reducing adult cigarette smoking prevalence to 12.0% (Office of Disease 

Prevention and Health Promotion n.d.). Similarly, current cigarette smoking among youth in grades 9–12 has 

declined from 36.4% in 1997 to 8.8% in 2017, a decline 

that has persisted in the two decades since the Master 

Settlement Agreement of 1998 and has surpassed the 

national Healthy People 2020 target of 16.0% (Centers 

for Disease Control and Prevention [CDC] n.d.). This commendable progress has been accomplished through the 

implementation of evidence-based tobacco control programs and policies at the federal, state, and local levels 

that effectively combat the tobacco use epidemic in the 

United States (Figure 8.1 and Table 8.1) (USDHHS 2012, 

2014). However, it is important to acknowledge that the 

tobacco product landscape has diversified in recent years. 

Although cigarettes remain the most commonly used 

tobacco product among U.S. adults (Wang et al. 2018), 

e-cigarettes have been the most commonly used tobacco

product among youth since 2014, and recent increases in

e-cigarette use have offset declines in cigarette smoking

and led to a net increase in overall tobacco product use

among youth (Gentzke et al. 2019).

The decline in cigarette smoking among adults have 

been driven, in part, by reductions in initiation among 

youth in recent years, especially over the past two decades 

(USDHHS 2012, 2014). For example, since 2002, cigarette smoking initiation and daily smoking initiation has 

decreased among youth 12–17 years of age of both sexes 

and among nearly all races/ethnicities (Cantrell et  al. 

2018). Preventing tobacco use among youth is therefore critical to reduce the overall prevalence of tobacco 

use because the vast majority of adult smokers initiate 

tobacco use as youth or young adults (USDHHS 2012). 

However, despite these notable accomplishments, motivating and helping people to quit smoking remains essential to (a) protecting the nation’s approximately 34 million 

adult cigarette smokers from a lifetime of addiction and 

tobacco-related disease and death (Wang et  al. 2018) 

and (b)  curbing the substantial financial costs incurred 

by society because of smoking-attributable healthcare 

spending and lost productivity (USDHHS 2014; Xu et al. 

2015). Accordingly, sustained efforts to increase access 

to and use of evidence-based cessation treatments among 

adult smokers, in coordination with population-based 

interventions, are essential to effectively address the full 

continuum of tobacco use from initiation to intermittent 

or routine use (USDHHS 2012, 2014).

Three decades after the first Surgeon General’s 

report to focus specifically on the health benefits of cessation, this report reviews and updates evidence on the 

importance of cessation in the context of a comprehensive tobacco control strategy. The report discusses historical patterns of smoking cessation in the United States, 

as well as the immediate and long-term health and economic benefits of smoking cessation at the individual and 

societal levels. The report also presents updated findings 

on biological insights into smoking cessation, including 

findings on nicotine addiction and genetic factors that 

may impact smoking behaviors. Finally, the report discusses the extensive array of clinical and population-based 

interventions that have been scientifically shown to effectively increase smoking cessation. The following sections 

discuss the past, present, and future of tobacco cessation 

in the United States. Specifically, these sections provide a 

historical perspective, discuss the current tobacco control 

landscape, and provide a vision for enhancing tobacco cessation in the United States.

Past: Historical Perspective

In 2010, USDHHS published the first tobacco control strategic action plan for the United States, Ending the 

Tobacco Epidemic: A Tobacco Control Strategic Action Plan 

for the U.S. Department of Health and Human Services

(USDHHS 2010). The main intent of this action plan was 

to reinvigorate national momentum toward advancing 

tobacco prevention and control by applying proven methods 

to reduce the burden of tobacco use and dependence. The 

50th anniversary Surgeon General’s report provided further 

scientific evidence for the effectiveness of the interventions 
A Report of the Surgeon General

644 Chapter 8Figure 8.1 Per capita annual cigarette consumption among adults, 18 years of age and older, and major smoking and health ev

1900–2017

Source: Adapted from Warner (1985) with permission from Massachusetts Medical Society, © 1985; as cited in USDHHS (2014).
A Vision for the Future 645

Smoking Cessation

Table 8.1 Summary of milestones aimed at increasing tobacco cessation in the United States

Year Event

1964 • 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

The first Surgeon General’s report, Smoking and Health, is released.

1967–1970 Regulation from the Federal Communications Commission requires broadcasters to apply the Fairness Doctrine 

to cigarette advertising to counter messages in advertising from the tobacco industry.

1971 Broadcast advertising of cigarettes ends.

Surgeon General Jesse Steinfeld called for a national “Bill of Rights for the Non-Smoker.”

1979 The Surgeon General’s report, Smoking and Health, is released. This report offers detailed reviews of major 

diseases and concludes that compared with smokers, risks are lower among former smokers for all-cause mortality, 

atherosclerosis and coronary heart disease, lung cancer, larynx cancer, lung function, and respiratory symptoms.

1984 Nicotine gum, available by prescription only, becomes the first FDA-approved cessation medication.

1986 The Surgeon General’s report, The Health Consequences of Involuntary Smoking, is released.

1987 The United States House of Representatives passed an amendment to the Federal Aviation Act, making domestic 

flights of 2 hours or less smokefree.

1988 The Surgeon General’s report, The Health Consequences of Smoking—Nicotine Addiction, is released.

1990 A congressionally mandated smoking ban takes effect on all domestic airline flights of 6 hours or less.

The Surgeon General’s report, The Health Benefits of Smoking Cessation, is released.

San Luis Obispo, California, becomes the first city in the world to eliminate smoking in all public buildings, including 

bars and restaurants.

1992 California lanches the first state-sponsored smoking cessation quitline.

1996 FDA approves the nicotine patch and gum for over-the-counter use and the nicotine nasal spray for prescription use.

The U.S. Public Health Service issues the first clinical practice guideline on Treating Tobacco Use and Dependence.

1997 FDA approves the nicotine inhaler and bupropion for prescription use for cessation. (Bupropion had previously 

been available as an antidepressant and continues to be available for this indication.)

1998 Attorneys General of 46 states sign the Master Settlement Agreement with the four largest tobacco companies in 

the United States. Among its provisions, the agreement prohibits tobacco advertising that targets people younger 

than 18 years of age.

California becomes the first state to pass a comprehensive statewide smokefree air law.

1999 CDC releases Best Practices for Comprehensive Tobacco Control with recommendations for tobacco cessation 

activities at the state level.

2000 The U.S. Public Health Service issues the second clinical practice guideline on Treating Tobacco Use and Dependence.

2002 The Joint Commission (on Accreditation of Healthcare Organizations) adds quality measures for treating tobacco 

dependence to accreditation requirements for hospitals.

FDA approves the nicotine lozenge for over-the-counter use.

2003 NCI launches the smokefree.gov cessation website.

University of California, San Francisco establishes the Smoking Cessation Leadership Center.

2004 USDHHS announces National Network of Quitlines; NCI’s 1-800-QUIT-NOW portal becomes operational; and CDC 

begins to dedicate funding for state quitlines.

The North American Quitline Consortium begins activities.

The Surgeon General’s report, The Health Consequences of Smoking, is released.

2006 The Surgeon General’s report, The Health Consequences of Involuntary Exposure to Tobacco Smoke, is released.

All 50 states, the District of Columbia, and Puerto Rico have publicly funded quitlines in place.

Massachusetts implements an evidence-based, heavily promoted Medicaid cessation benefit.

FDA approves varenicline for prescription use, making it the seventh FDA-approved cessation medication.

2007 The Multistate Collaborative for Health Systems Change is established.

2008 The U.S. Public Health Service issues the third clinical practice guideline on Treating Tobacco Use and Dependence, 

2008 Update.

2009 Federal tax increase of $0.62 per pack of cigarettes raises the federal tax to $1.01 per pack of cigarettes.

The Family Smoking Prevention and Tobacco Control Act is enacted.
A Report of the Surgeon General

646 Chapter 8

Table 8.1 Continued

Year Event

2010 • 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

President Obama signs the Patient Protection and Affordable Care Act into law. The law includes important provisions 

that expand tobacco cessation benefits and establishes the Prevention and Public Health Fund, which provides funds

to prevent and reduce tobacco use.

Recording the smoking status in the electronic health records of all patients 13 years of age and older becomes a 

required measure to track and report as part of the Patient Protection and Affordable Care Act.

The first tobacco control strategic action plan for the United States, Ending the Tobacco Epidemic: A Tobacco Control 

Strategic Action Plan for the U.S. Department of Health and Human Services, is published.

2011 OPM implements an evidence-based cessation benefit for federal employees.

NCI launches SmokefreeTXT, a cessation program administered via mobile text messaging.

2012 The Joint Commission’s set of tobacco cessation measures for hospitals is strengthened to define required components 

of evidence-based treatment for tobacco dependence and becomes available for voluntary adoption by hospitals. 

CDC launches Tips From Former Smokers, the first federally funded, national tobacco education campaign.

The University of California, San Diego, launches the Asian Smokers’ Quitline.

2013 NCI and CDC launch 1-855-DEJELO-YA portal for Spanish speakers.

2014 The Surgeon General’s report The Health Consequences of Smoking—50 Years of Progress is released.

CDC publishes a new edition of Best Practices for Comprehensive Tobacco Control Programs that includes updated 

recommendations for tobacco cessation activities at the state level.

The U.S. Departments of Labor, Health and Human Services, and the Treasury issue subregulatory guidance that 

clarifies the tobacco cessation coverage requirements in the Patient Protection and Affordable Care Act.

Major components of the Patient Protection and Affordable Care Act are implemented, including new health 

insurance options and requirements that most private health plans must cover preventive services, including 

a comprehensive quit smoking benefit. As part of another key component, Medicaid is expanded to provide a 

comprehensive quit smoking benefit to millions of low-income Americans.

2015 The U.S. Preventive Services Task Force issues updated recommendations for tobacco cessation.

CDC launches the 6/18 initiative, partnering with healthcare purchasers, payers, and providers to improve health 

and control costs. The initiative focuses on the reduction of tobacco use, which is a costly health condition with 

proven interventions.

2017 Inpatient psychiatric facilities are required, as part of the Inpatient Psychiatric Facility Quality Reporting program, 

to report on the Joint Commission’s set of tobacco cessation measures for hospitals.

2018 FDA launches the Every Try Counts media campaign that encourages smokers to quit smoking.

Notes: CDC = Centers for Disease Control and Prevention; FDA = U.S. Food and Drug Administration; NCI = National Cancer Institute; 

OPM = Office of Personnel Management; USDHHS = U.S. Department of Health and Human Services.

the percentage who have tried to quit has increased 

slowly over the past two decades.

However, several key findings of this report highlight the tragic public health history of tobacco use in 

this country, including the continued legacy of millions 

of lives prematurely lost from this deadly and completely 

preventable health risk factor:

• Each year, less than 1 in 10 U.S. adult cigarette 

smokers successfully quits smoking (defined as being 

quit for at least 6 months at the time of the survey 

interview);

• Disparities in cessation remain by age, race/

ethnicity, educational attainment, socioeconomic 

status, healthcare insurance coverage, geography, 

and other factors;

described in the national action plan (USDHHS 2014). 

The report concluded that, “Comprehensive tobacco control programs and policies have been proven effective 

for controlling tobacco use. Further gains can be made 

with the full, forceful, and sustained use of these measures” (USDHHS 2014, p. 7). The evidence outlined in this 

Surgeon General’s report reinforces that conclusion and 

provides compelling evidence related to the successes of 

these measures in the context of cessation:

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

were ever cigarette smokers have quit smoking;

• More than two-thirds of U.S. adult cigarette smokers 

report interest in quitting cigarette smoking; and

• The majority of adult cigarette smokers in the United 

States have tried to quit during the past year, and 
A Vision for the Future 647

Smoking Cessation

• Interest in quitting is declining among high school

students who are smokers, and the proportion

who made a quit attempt during the past year has

decreased over the past two decades;

• Support to quit smoking, in the form of advice from

health professionals and assistance from clinicians,

remains inadequate; and

• More than two-thirds of adult cigarette smokers in

the United States who tried to quit during the past

year did not use evidence-based cessation counseling 

or medication.

Despite progress over the past half century, challenges persist with regard to ensuring that the risks of cigarette smoking and the benefits of cessation are addressed 

by implementing evidence-based strategies in a timely 

manner and by sustaining these strategies over time. 

In  2000, Surgeon General Dr. David Satcher acknowledged a recurring theme that still plagues the tobacco 

control movement today: “Our lack of greater progress in 

tobacco control is more the result of failure to implement 

proven strategies than it is the lack of knowledge about 

what to do” (USDHHS 2000). To that end, several advances 

have been made to better understand the immediate and 

long-term benefits of smoking cessation and of effective 

cessation interventions. However, these strategies have 

not necessarily been implemented in a timely, equitable, 

and sustainable manner (USDHHS 2014). The comprehensive body of scientific evidence that has emerged since 

the first Surgeon General’s report on cessation nearly 

three decades ago (USDHHS 1990) makes it even more 

important that we act on this knowledge and immediately 

implement effective cessation strategies.

When first introduced in the U.S. marketplace in the 

mid-1980s and early 1990s, nicotine replacement therapy 

(NRT) was available only by prescription (USDHHS 1990; 

JAMA: the Journal of the American Medical Association 

2000). However, a growing body of scientific evidence on the safety of NRT led the U.S. Food and Drug 

Administration (FDA) to make certain NRT products available over the counter. In 1996, FDA approved the transition of certain NRT products from being available by 

prescription only to being available over the counter to 

enhance their availability and use (JAMA: the Journal of 

the American Medical Association 2000). In the same year, 

the U.S. Agency for Health Care Policy and Research formally recommended that NRT be part of standard care for 

every adult smoker (Fiore et al. 1996).

As evidence on the efficacy of tobacco cessation interventions continued to grow, the U.S. Public Health Service 

(JAMA: the Journal of the American Medical Association 

2000) released A Clinical Practice Guideline for Treating 

Tobacco Use and Dependence. As noted in the guideline, 

a considerable increase in research during the previous 

two decades had clarified the nature of tobacco dependence as a chronic disease, the addictive nature of nicotine, and the availability of multiple effective behavioral 

counseling and pharmacological strategies for treating 

tobacco use and dependence (JAMA: the Journal of the 

American Medical Association 2000). Based on this evidence, the guideline provided specific recommendations 

regarding brief and intensive tobacco cessation interventions, as well as systems-level changes designed to promote the assessment and treatment of tobacco use. These 

recommendations were updated in Treating Tobacco Use 

and Dependence: 2008 Update (Fiore et al. 2008). The 2008 

guideline concluded that “tobacco dependence is a chronic 

disease that often requires repeated intervention and multiple attempts to quit” (Fiore et al. 2008, p. vi). It provided 

healthcare professionals with additional effective treatment strategies that had not been identified in the 2000 

guideline, such as stronger evidence on the effectiveness of 

counseling, evidence that quitline counseling is effective, 

and recommendations related to the efficacy of all seven 

first-line pharmacotherapies that are approved by FDA for 

smoking cessation. These seven medications include five 

nicotine-based medications (the nicotine patch, gum, lozenge, nasal spray, and oral inhaler) and two non-nicotine 

oral medications (bupropion and varenicline). Of note, the 

2008 guideline also reinforced the increasing body of evidence demonstrating that the successful implementation 

of nicotine dependence treatment strategies depends on 

support from the healthcare system in which the strategies are embedded. To that end, the guideline presented 

new evidence about the critical role the healthcare system 

plays in increasing the likelihood that clinicians consistently identify and intervene with smokers and that 

smokers receive and use effective nicotine dependence 

treatments and successfully quit. The 2008 guideline also 

underlines the failure to fully implement proven tobacco 

cessation interventions: “Indeed, it is difficult to identify 

any other condition that presents such a mix of lethality, 

prevalence, and neglect, despite effective and readily available interventions” (Fiore et al. 2008, p. 12).

In 2009, following the release of the 2008 guideline, landmark advancements helped to shape the regulatory landscape for tobacco products in the United 

States. In June 2009, the Family Smoking Prevention and 

Tobacco Control Act (Tobacco Control Act) gave, for the 

first time in history, FDA the authority to regulate the 

manufacturing, marketing, and sale of tobacco products. 

The statute empowered FDA to regulate tobacco products 

in a manner that is “appropriate for the protection of public 

health” (Tobacco Control Act 2009, §907(a)(3)(A)), which 
A Report of the Surgeon General

648 Chapter 8

was an unprecedented and critical departure from the 

standard of safety and efficacy that had governed the regulation of human drugs and medical devices. For example, 

the Tobacco Control Act gives FDA the authority to promulgate regulations respecting the construction; components; ingredients; additives; constituents, including 

smoke constituents; and properties of cigarettes, but the 

Act prohibits the agency from reducing nicotine yields in 

these products to zero. The Act also requires FDA to consider the individual- and population-level health effects 

of its regulatory actions, including their impact on cessation. Despite these provisions, FDA has faced some legal 

challenges (Public Health Law Center 2019). Nonetheless, 

FDA authority over tobacco products has been, and continues to be, an instrumental lever to reduce tobacco use 

and its harms using a population-based standard. Ongoing 

FDA actions related to this authority have the potential to 

advance population-based cessation efforts, including

• Regulating existing tobacco products and their 

constituents;

• Conducting a premarket review of new tobacco 

products before they can be introduced into the 

marketplace; 

• Evaluating modified risk claims and products and 

requiring premarket testing and postmarket surveillance to evaluate the potential consequences of 

introducing these products into the marketplace;

• Educating the public about the harms of tobacco 

products (Zeller 2012; USDHHS 2014).

In March 2010, the Patient Protection and Affordable 

Care Act (Affordable Care Act) (2010) was signed into law. 

In the context of cessation, the law

• Requires most private insurance plans and all 

Medicaid expansion plans to cover in network tobacco 

cessation with no cost-sharing;

• Requires state Medicaid programs to cover all seven 

FDA-approved tobacco cessation medications;

• Requires states to provide a comprehensive cessation benefit, including coverage of cessation counseling and medication, for pregnant women enrolled 

in Medicaid; and

• Provides Medicare beneficiaries with an annual wellness visit that includes referrals for tobacco cessation services.

By contributing to improved Medicaid and private 

cessation coverage and increasing the number of smokers 

who have insurance coverage, the Affordable Care Act has 

increased smokers’ access to proven cessation treatments, 

which will improve their chances of quitting (McAfee et al. 

2015). Specifically, the Act requires Grade A or B recommendations from the U.S. Preventive Services Task Force 

to be covered without cost-sharing. Since the implementation of the Affordable Care Act, some progress has occurred 

in traditional state Medicaid coverage of proven tobacco 

cessation treatments: The number of states covering individual and group counseling and all seven FDA-approved 

cessation medications increased from 7 states at the end 

of 2008 to 15 states at the end of 2018, and the number of 

states covering all seven FDA-approved cessation medications increased from 20 states at the end of 2008 to 36 states 

at the end of 2018. However, cessation coverage still falls 

short of a comprehensive benefit across all 50 states and 

the District of Columbia, and nearly all states retain barriers—such as prior authorization, duration limits, and 

copayments—that make it difficult for Medicaid enrollees 

to access cessation treatments (DiGiulio et al. 2018).

Effective August 2016, FDA finalized a rule that 

extended its regulatory authority to all tobacco products, 

except for accessories of newly deemed products, including 

electronic cigarettes (e-cigarettes), cigars, hookah and 

pipe tobacco, and future tobacco products, as part of its 

goal to improve public health. Known as the “deeming 

rule,” the rule makes these products subject to regulatory 

requirements imposed by or authorized under the Tobacco 

Control Act, including federal prohibition on free sampling for most tobacco products, federal requirements for 

health warnings, and the requirement that tobacco manufacturers register with FDA and seek the agency’s review 

of new tobacco products (FDA 2018a). Of important note, 

the deeming rule does not preempt states and localities 

from implementing laws related to tobacco product sales, 

use, distribution, and advertising, as long as the laws are 

in addition to, or more stringent than, the requirements of 

the Tobacco Control Act (FDA 2018a). Expanding the diversity of tobacco products under the regulatory jurisdiction 

of FDA enhanced the agency’s ability to effectively regulate 

these products in a manner that is appropriate for the protection of public health, as directed by the U.S. Congress. As 

was concluded in the 50th anniversary Surgeon General’s 

report, “The burden of death and disease from tobacco use 

in the United States is overwhelmingly caused by cigarettes and other combusted tobacco products” (USDHHS 

2014, p. 7), thus reinforcing the importance of regulatory 

actions to address the variety of combustible tobacco products being sold and used in the United States. The report 

further noted that “the cigarette is also a defective product, 

meaning not just dangerous but unreasonably dangerous, 
A Vision for the Future 649

Smoking Cessation

killing half of its long-term users” (Proctor 2013, p. i27, 

as cited in USDHHS 2014). The report also noted that a 

variety of noncombustible and electronic tobacco products with the potential for modified risk are being developed and aggressively marketed. Further, it noted that the 

shift in patterns of tobacco use could have several potential 

impacts, ranging from the positive effect of accelerating 

the rates of complete cessation among adult smokers to 

the negative effects of delaying cessation and diminishing 

progress in reducing the use of all forms of tobacco products, especially among youth and young adults. However, 

the impact of these products on population health is considerably more likely to be beneficial in an environment 

where the appeal, accessibility, promotion, and use of cigarettes and other combustible tobacco products are being 

rapidly reduced and effectively regulated, most notably 

among youth and young adults (USDHHS 2014).

These major developments in the federal regulatory 

landscape since the release of the last Surgeon General’s 

report on cessation in 1990, coupled with the extensive and 

growing body of science documenting evidence-based clinical and population-based strategies for reducing tobacco 

use and motivating and helping tobacco users to quit, 

have created a strong foundation for achieving success in 

helping the nation’s 34  million adult cigarette smokers 

quit for good. Increased implementation of proven tobacco 

control strategies would accelerate progress; however, the 

present levels of implementation of these strategies are 

unacceptably low and fall well below optimally effective 

levels based on the existing body of scientific evidence. 

Of particular note, state funding for tobacco control programs has been declining for more than a decade (CDC 

2014; Campaign for Tobacco-Free Kids 2018); this funding 

includes support for state cessation interventions, which 

is one of CDC’s five recommended components of a comprehensive state tobacco control program (CDC 2014). For 

example, in fiscal year 2019, states will collect $27.3 billion 

from taxes and payments as a result of the tobacco Master 

Settlement Agreement of 1998. However, states will spend 

just 2.4% of this revenue—$655  million—on tobacco 

control programs, including efforts to help smokers quit 

(Campaign for Tobacco-Free Kids 2018). The enormous 

health and financial burden of smoking-attributable disease, disability, and death in the United States will continue for decades unless comprehensive, meaningful, sufficiently funded, and evidence-based actions take hold at 

the national, state, and local levels. Although the nation 

is on the cusp of reaching the Healthy People 2020 objective of reducing the prevalence of smoking among adults 

18  years of age and older to 12.0% (Wang et  al. 2018), 

more can and should be done to help implement the 

proven interventions that are readily available.

Present: Health Benefits of Cessation

Even more than 50 years after the first Surgeon 

General’s report on smoking, the number of diseases and 

other adverse health effects caused by smoking continues 

to grow as the available scientific evidence has expanded 

with time (U.S. Department of Health, Education, and 

Welfare 1964; USDHHS 2004, 2010, 2014). The conclusions in earlier Surgeon General’s reports on tobacco use 

have focused primarily on causal associations between 

smoking and increased risk of disease and other adverse 

health outcomes, largely because of the lack of a sufficient 

body of scientific evidence at the time on the link between 

smoking cessation and decreased risk of such outcomes. 

The 1990 report was the first Surgeon General’s report to 

comprehensively synthesize the available scientific evidence on the health benefits of smoking cessation. That 

report concluded that smoking cessation has major and 

immediate health benefits for men and women of all 

ages (USDHHS 1990). Specifically, the report concluded 

that compared with continued smoking, smoking cessation reduces rates of respiratory symptoms and respiratory infections, such as bronchitis and pneumonia. The 

report also reached conclusions related to the short- and 

long-term benefits of cessation. For example, smoking 

cessation improves pulmonary function by about 5% in 

only a few months after quitting smoking. Moreover, with 

sustained abstinence from smoking, the rate of decline in 

pulmonary function among former smokers returns to 

that of never smokers, and mortality rates from chronic 

obstructive pulmonary disease decline among former 

smokers compared with rates among persons who continue to smoke (USDHHS 1990). This report expands on 

the findings of the 1990 report, reaching several important new conclusions about the specific health benefits of 

smoking cessation, including

• Smoking cessation benefits persons at any age, but

the benefits are greater at younger ages compared

with older ages;

• Smoking cessation improves well-being, including

higher quality of life and improved health status;

• Smoking cessation reduces the risk of the following

cancers: lung, larynx, oral cavity and pharynx,
A Report of the Surgeon General

650 Chapter 8

esophagus, pancreas, bladder, stomach, liver, cervix, 

kidney, colorectal, and acute myeloid leukemia;

• Smoking cessation substantially reduces the risk of 

coronary heart disease among men and women of 

all ages and reduces risk of morbidity and mortality 

from stroke and cardiovascular diseases; and

• Smoking cessation by pregnant women benefits their 

health and that of their fetuses and newborns.

In addition to significant health benefits to individual smokers and society, smoking cessation also has 

considerable economic benefits. Smoking cessation can 

reduce the costs of smoking for individual smokers, health 

systems, and society. Moreover, the report finds that 

smoking cessation interventions are cost-effective. The 

report documents an array of effective clinical and health 

systems interventions for increasing smoking cessation 

and treating tobacco use and dependence:

• Behavioral counseling and cessation medication 

interventions increase smoking cessation compared 

with self-help materials or no treatment.

• Behavioral counseling and cessation medications 

are each effective alone in treating tobacco use and 

nicotine addiction but are most effective when used 

in combination.

• Combination pharmacotherapy, including combining short- and long-acting forms of NRT, increases 

smoking cessation compared with the use of single 

forms of NRT.

• Tobacco quitline counseling increases smoking cessation, when provided alone or in combination with 

medication.

• Insurance coverage of cessation interventions that 

are comprehensive, barrier-free, and evidence-based 

increases the availability and utilization of treatment services for smoking cessation.

This report further reinforces the importance of 

interventions promoting cessation at the individual and 

population levels. Specifically, actions at the clinical and 

health system levels are typically designed to integrate 

tobacco cessation interventions into routine clinical care, 

increase the use and effectiveness of smoking cessation 

treatments, or directly help smokers quit. However, such 

interventions should not function in isolation. Instead, 

they should complement population-based interventions that have already been shown in multiple previous 

Surgeon General’s reports (USDHHS 2004, 2014) and 

other major reports to reduce tobacco use and tobaccorelated morbidity and mortality. Given the critical importance and impact of population-based interventions in 

combating the tobacco use epidemic, King and Graffunder 

(2018) described the importance of such strategies in the 

context of a “tobacco control vaccine,” whose ultimate 

impact on public health is contingent on its combination 

of individual components (including a “cessation access” 

component), robust population-level protection, and the 

extent to which these components are supported and 

advanced by key stakeholders at an adequate dose. In addition to preventing initiation of tobacco product use, 

population-based interventions can also influence cessation at a macro level by motivating tobacco users to quit 

and by providing an environment that makes it easier for 

them to do so (CDC 2014). Although previous Surgeon 

General’s reports have documented the efficacy of these 

interventions for reducing tobacco use, this is the first 

Surgeon General’s report to document the impact of such 

interventions on smoking cessation:

• Increasing the price of cigarettes reduces cigarette 

consumption, reduces the prevalence of smoking, 

and increases smoking cessation;

• Mass media campaigns increase the number of calls 

to quitlines and increase smoking cessation;

• Smokefree policies lead to decreased prevalence 

of smoking, decreased cigarette consumption, and 

increased smoking cessation among adults; and

• Comprehensive state tobacco control programs 

reduce the prevalence of smoking and increase 

smoking cessation.

Predictive models described in this report show that 

evidence-based tobacco control policies can yield substantial reductions in the prevalence of smoking. Moreover, 

cessation treatment policies and other policies—including 

tax increases, smokefree laws, and media campaigns—

have complementary effects by increasing quit attempts 

and improving quitting success. Taken together, the preponderance of available data on the benefits of cessation 

and the efficacy of available clinical and population-based 

interventions reinforces the importance of a comprehensive approach to promoting tobacco cessation in the 

United States. While acknowledging the importance of 

the individual components, it is critical to recognize that 

these individual components must work together synergistically to most effectively prevent initiation of tobacco 

use and promote cessation (CDC 2014; USDHHS 2014).
A Vision for the Future 651

Smoking Cessation

Future: Ending the Tobacco Use Epidemic

Progress and Challenges

Tobacco use could remain the leading cause of preventable disease, disability, and death in the United States 

unless the prevalence of tobacco use, especially use of combustible products, is reduced more rapidly than the current 

trajectory (USDHHS 2014). Such reductions will require 

coordinated efforts to prevent initiation of tobacco use and 

nicotine addiction among young people and to create an 

environment that promotes and supports cessation among 

current tobacco users (USDHHS 2014). Considerable 

progress has been made but more can be done—and with 

enhanced expediency. To end the tobacco use epidemic, the 

evidence-based strategies articulated in this report must be 

implemented fully and sustained with sufficient intensity 

and duration. If this does not happen, nearly half a million 

Americans will continue to die each year from smokingrelated diseases and exposure to secondhand smoke, and 

millions of Americans will continue to live with serious 

smoking-related diseases, costing society hundreds of billions of dollars in smoking-attributable healthcare expenditures and lost productivity (USDHHS 2014).

Challenges remain to accomplish the goal of a society 

free of tobacco-related death and disease. For example, 

marked disparities exist in the use of tobacco products, and 

some subpopulations face a considerably higher burden of 

tobacco use and tobacco-associated morbidity and mortality. Use of tobacco products remains higher among 

males, middle-aged adults, American Indians/Alaska 

Natives, persons with lower levels of education, persons 

living below the poverty level, persons living in the Midwest 

and South, persons with no health insurance or who are 

insured through Medicaid, sexual and gender minorities, persons with disabilities, and persons with behavioral health conditions (Wang et al. 2018). Additionally, 

as noted in this report, marked disparities in cessation 

persist across population groups. Disparities also persist 

regarding access to and use of proven cessation treatments 

(National Cancer Institute [NCI] 2017). The prevalence of 

key indicators of cessation—quit attempts, advice to quit 

from a health professional, and access to cessation therapies—varies across populations, with lower prevalence 

among some vulnerable subgroups. For example, uninsured smokers and Hispanic smokers are less likely than 

their respective counterparts to report receiving advice 

to quit from a health professional; uninsured smokers, 

Hispanic smokers, and gay/lesbian/bisexual smokers are 

less likely than their counterparts to report using cessation counseling and/or medication as part of a quit attempt 

(Babb et al. 2017). To eliminate tobacco-related disparities, 

tobacco control programs and policies, including barrierfree access to cessation treatments, must be implemented 

in a way that achieves equitable benefits for all (CDC 

2014). Such efforts would ultimately enhance access to 

effective cessation treatments and accelerate the decline 

in the prevalence of smoking across all population groups, 

thus alleviating the disproportionate health and economic 

burden experienced by vulnerable population groups (CDC 

2014; NCI 2017).

Disparities in tobacco use and cessation are compounded by the fact that the tobacco industry continues 

to aggressively market and promote addictive and lethal 

products with the goals of retaining current users of these 

products and of recruiting new consumers, including 

youth and young adults (USDHHS 2012). Such marketing and promotional activities, including decades of 

coordinated efforts targeting various vulnerable population groups, have contributed to the disparities in cigarette smoking and cessation that exist in the United States 

(USDHHS 1998, 2014; NCI 2008, 2017). The 50th anniversary Surgeon General’s report further underscored the 

deceptive nature of the tobacco industry’s efforts, reaching 

the following major conclusion: “The tobacco epidemic 

was initiated and has been sustained by the aggressive 

strategies of the tobacco industry, which has deliberately 

misled the public on the risks of smoking cigarettes” 

(USDHHS 2014, p. 7).

The landscape of tobacco products continues to 

evolve to include an array of combustible, noncombustible, and electronic products (Cullen et  al. 2018; Wang 

et al. 2018). For example, heated tobacco products have 

recently reentered the U.S. marketplace, with IQOS being 

authorized by FDA for sale in April  2019 (FDA  2019). 

More research is needed to better understand the longterm health effects of heated tobacco products. Although 

preliminary data from the tobacco industry suggest certain heated tobacco products generally have lower levels 

of harmful ingredients than conventional cigarettes 

(St. Helen et al. 2018), concerns remain around sustained 

dual use of heated products and conventional cigarettes, 

youth initiation, and the limited number of independent 

studies assessing the constituents in these products and 

the potential population-level health risks (Leigh et  al. 

2018; Max et al. 2018; McKelvey et al. 2018; Nabavizadeh 

et al. 2018). At present, data are not available on the longterm health effects of these products.

The continued diversification of the tobacco product 

landscape could have several different potential impacts, 

ranging from accelerating the rates of complete cessation among adult smokers to delaying cessation and 
A Report of the Surgeon General

652 Chapter 8

diminishing progress in reducing the use of all forms 

of tobacco products among youth and young adults 

(USDHHS 2014). Moreover, as the landscape of tobacco 

products continues to evolve, so does the tobacco industry. 

For example, during the past decade, three categories 

of e-cigarette brands have emerged in the U.S. market: 

brands developed by cigarette manufacturers, brands that 

were ultimately acquired by cigarette manufacturers, and 

brands that have no affiliation with cigarette manufacturers (USDHHS 2016). In recent years, the majority of 

e-cigarettes sold in traditional retail stores are those manufactured by major cigarette companies (King et al. 2018). 

More recently, the tobacco industry has also made more 

prominent efforts to acquire a stake in e-cigarette companies not previously affiliated with the traditional tobacco 

industry. For example, in December 2018, Altria Group, 

the parent company of Philip Morris USA, purchased a 

35% stake in JUUL Labs, the maker of the most commonly 

sold e-cigarette in the United States (Altria Group 2018).

The increasing availability and use of novel tobacco 

products, most notably e-cigarettes, raise questions about 

the potential impact that such products could have on 

efforts to eliminate the individual- and population-level 

disease and death caused by tobacco use. However, when 

considering the impact of e-cigarettes on public health, it’s 

critical to acknowledge their potential benefits and their 

potential risks, including the recognition that populationlevel increases in youth using e-cigarettes and becoming 

addicted to nicotine could offset any potential benefits 

realized among adult smokers using these products to 

quit. Additionally, e-cigarette, or vaping, product use may 

be associated with other health risks beyond youth initiation and use. For example, CDC, FDA, state and local 

health departments, and public health and clinical partners have been investigating a multistate outbreak of 

e-cigarette, or vaping, product use associated lung injury 

(EVALI) (Siegel et al. 2019). The latest national and state 

findings show e-cigarette, or vaping, products containing 

THC—particularly those from informal sources, such as 

friends, family, or in-person or online dealers—are linked 

to most of the cases of lung injury and play a major role in 

the outbreak (Moritz et al. 2019; Navon et al. 2019). In particular, vitamin E acetate is closely associated with EVALI 

(Blount et  al. 2019). Vitamin  E acetate has been identified in several tested products used by EVALI patients, 

and has been identified in bronchoalveolar lavage (BAL) 

fluid samples from 48 of 51 assessed EVALI patients, but 

not in the BAL fluid from a control group. However, as of 

January 2020, evidence is not yet sufficient to rule out the 

contribution of other chemicals of concern among some 

EVALI patients.

The Tobacco Control Act is governed by a requirement to protect the overall public health. Such a 

population-level public health standard is essential because 

exposure to harmful toxicants from e-cigarettes at the 

individual level could adversely affect public health at the 

population level by (a) increasing initiation of e-cigarette 

use and nicotine addiction among vulnerable populations, 

including young people, and (b)  increasing the number 

of adult users of both combustible tobacco products and 

e-cigarettes (i.e., dual users) without necessarily increasing 

the number of successful adult quitters. Weighing the 

relative benefits and risks to individuals and the population as a whole is essential when considering the potential 

role that any noncombustible tobacco product may play 

in reducing the occurrence of smoking-attributable disease and death (USDHHS 2014). E-cigarettes could help 

individual adult smokers if they completely switch from 

conventional cigarettes to e-cigarettes. Among those who 

have transitioned completely, the ultimate goal should be 

to also quit the use of e-cigarettes completely to achieve 

the maximal individual and public health benefit. However, 

at the population level, any potential benefits these products confer in terms of increasing cessation among adult 

smokers would need to outweigh potential risks related to 

increased initiation of tobacco product use among youth 

(USDHHS 2014). E-cigarette use among U.S. high school 

students increased 78% during 2017–2018, as 1 in 4 high 

school students reported currently using e-cigarettes in 

2019 (Cullen et  al. 2019). This increase coincided with 

the growing popularity of e-cigarettes shaped like a USB 

flash drive, including JUUL (King et  al. 2018; Gentzke 

et  al. 2019). Many of these e-cigarettes deliver nicotine 

in the form of nicotine salts, which allow users to inhale 

particularly high levels of nicotine more easily and with 

less irritation than the freebase nicotine that is used traditionally in tobacco products, including older generation 

e-cigarettes (USDHHS 2018). These high levels of nicotine 

introduce additional population-level risks because nicotine is extremely addictive, can harm the developing brain 

in adolescents, and can prime the brain for addiction to 

other drugs (USDHHS 2016).

It is also critical to acknowledge that for e-cigarettes 

or other noncombustible tobacco products to be effective 

harm-reduction tools, they must help smokers completely 

quit conventional cigarettes. Specifically, users must transition completely from combustible tobacco products to 

lower risk alternatives in order to realize a reduction in 

risk at the individual level. As noted in the major conclusions of this report, e-cigarettes, a continually changing 

and heterogeneous group of products, are used in a variety 

of ways; and there is presently inadequate evidence to conclude that e-cigarettes, in general, increase smoking cessation. Moreover, the available evidence indicates that a 

majority of e-cigarette users also smoke conventional cigarettes—a pattern of use that does not confer a substantial 
A Vision for the Future 653

Smoking Cessation

risk reduction benefit to the individual (USDHHS 2014; 

Goniewicz et  al. 2018). However, the number and scientific rigor of studies on e-cigarettes and smoking cessation among adults continue to increase (Hajek et  al. 

2019), and a growing body of scientific evidence suggests 

that multiple factors related to e-cigarettes—including 

product type, frequency of use, and efficiency of nicotine delivery—could affect the efficacy of these products 

for successful smoking cessation. Of note, the diversification of the e-cigarette landscape is especially important 

to consider in the context of cessation efficacy, as various 

aspects of these products—including their ability to efficiently deliver nicotine to the user—have evolved with 

each generation of e-cigarette product that has entered 

the marketplace. For example, although justifiable concerns exist that nicotine salts could promote initiation of 

e-cigarette use among youth, this new product formulation also has the potential to enhance the dose and efficiency with which nicotine is delivered to adult smokers

who may be attempting to quit smoking, thus potentially

increasing the likelihood that they are able to transition completely to e-cigarettes. However, this formulation could also make it more difficult for those who fully

transition to e-cigarettes to eventually quit using these

products completely.

Studies on the relationship between e-cigarettes and 

smoking cessation continue to emerge, including randomized clinical trials that will be critical to providing a 

comprehensive and evidence-based understanding of this 

topic. When considering current and future studies on 

e-cigarettes, it is important to note that findings may not

be generalizable to all settings, including smokers who

have different levels of dependency than those included in

the reported research; smokers who try or use e-cigarettes

for reasons other than quitting smoking; and smokers

who live in countries that have different policy and regulatory environments, including limitations on the amount

of nicotine permitted in e-cigarettes and restrictions on

e-cigarette advertising and marketing. Also, e-cigarettes

are not a uniform product category; the generalizability

of research on their efficacy for smoking cessation is complicated by the diversity of products available, the volatile nature of the marketplace, and the extent to which

the products can be modified by the user—including

modifications that affect the level of nicotine the products deliver. More longitudinal research is needed on

the long-term health effects of using e-cigarettes and

on the effects of e-cigarette use on cessation, including

research addressing internal validity and generalizability

to real-world usage. Additionally, given the volatility of the

e-cigarette landscape, including the introduction of nicotine salts, research on different types of e-cigarette products and frequency of use is essential.

As studies on e-cigarettes and cessation continue to 

emerge, it is critical that public health recommendations 

be based on a robust and scientifically rigorous evidence 

base that takes into account the potential detrimental 

impacts that the widespread availability and promotion of 

e-cigarettes for cessation could have on youth initiation of

e-cigarettes, as well as other tobacco products (USDHHS

2016). When considering public health, in order for a net

gain to occur, any benefit of e-cigarette use among adult

smokers would have to outweigh the risks of increased initiation among young people at the population level.

End-Game Strategies

Faced with the challenge of realizing the vision of 

a society free of tobacco-related death and disease, and 

especially given the increasing variety of tobacco products 

in the marketplace, the patterns of use of these products 

among adults and youth, and the changing demographics 

of users of these products, the 50th anniversary Surgeon 

General’s report summarized several potential end-game 

strategies and emphasized those judged most relevant 

for the United States (Table 8.2) (USDHHS 2014). These 

proposed strategies, in conjunction with the accelerated 

implementation of proven tobacco control interventions, 

are intended to end the epidemic of disease and premature death caused by tobacco use. The development of various end-game strategies by scholars around the world has 

taken place in the absence of a broad consensus on how 

to define the end related to tobacco. For example, some 

end-game strategies have focused on the elimination of all 

tobacco use and the use of any nicotine-containing products, including e-cigarettes; others have focused on eliminating the use of combustible tobacco products because 

to date, these products have been responsible for the overwhelming burden of death and disease caused by tobacco 

use (USDHHS 2014). Nonetheless, there is generally broad 

recognition and consensus that the overriding objective is 

to maximize health (USDHHS 2014).

Benowitz and Henningfield (1994) made one of the 

first end-game proposals, describing a policy approach of 

gradually reducing the levels of nicotine content in cigarettes to nonaddictive levels, so as to prevent the development of nicotine addiction in youth. The authors also 

noted that this strategy could increase the likelihood that 

adult smokers would stop smoking—as cigarettes would 

become “less satisfying.” In the decades since that 1994 

publication, several studies have assessed the potential 

impact of experimental very-low-nicotine-content cigarettes on adult smokers. Based on these studies, this 

report finds that reducing the level of nicotine content 

in cigarettes could have the potential to reduce smoking: 
A Report of the Surgeon General

654 Chapter 8

The evidence is suggestive but not sufficient to infer that 

very-low-nicotine-content cigarettes can reduce smoking 

and nicotine dependence and increase smoking cessation 

when full-nicotine cigarettes are readily available; the 

effects on cessation may be further strengthened in an 

environment in which conventional cigarettes and other 

combustible tobacco products are not readily available.

Moreover, a simulation model by Apelberg and colleagues (2018) suggested that if conventional cigarettes 

were not available, lowering the level of nicotine content in cigarettes to minimally addictive levels in the 

United States would decrease the prevalence of cigarette 

smoking to 1.4% by 2060, prevent 16  million people 

from initiating smoking, and avert an estimated 2.8 million tobacco-related deaths. Of all end-game strategies 

proposed to date, nicotine reduction has received the 

greatest interest and attention in the United States, in 

part because the regulatory structure required to implement it is already in place and is explicitly articulated in 

the Tobacco Control Act. In 2018, FDA issued an advance 

notice of proposed rulemaking that specifically requested 

data and other information to inform a potential tobacco 

product standard to reduce nicotine in cigarettes to minimally addictive or nonaddictive levels for the protection 

of public health (Federal Register 2018; FDA 2018a). The 

Tobacco Control Act gives FDA several tools to regulate 

cigarettes, including the ability to establish product standards, which could include reducing nicotine content to 

levels so low that they would be insufficient to cause or 

sustain nicotine addiction, but the Act expressly prohibits 

FDA from requiring the reduction of nicotine yields of 

cigarettes to zero. However, questions of potential interest 

related to a standard could include whether such a nicotine standard would lead to smokers inhaling more deeply 

to compensate for the reduced nicotine yield; would lead 

to illicit trade in products with higher nicotine yield; and 

would impact vulnerable populations with higher rates of 

smoking, such as those with mental illness and substance 

use disorders (USDHHS 2014; Gottlieb and Zeller 2017).

In addition to a potential standard around the level 

of nicotine content, several other end-game proposals also 

have the potential to contribute to increases in smoking 

cessation and reductions in the disease and premature 

death caused by tobacco. For example, strict standards 

for ingredients in tobacco products could be established 

to make some or all tobacco products less toxic and 

less appealing, particularly to young people (Table  8.2). 

The Tobacco Control Act authorizes FDA to implement 

product standards to control levels of chemicals and other 

ingredients in tobacco products or their emissions for the 

protection of public health (USDHHS 2014). Other potential end-game strategies could aim to reduce the supply 

of tobacco products, which could also influence cessation among current users of such products, or to prohibit the sale of cigarettes and/or other tobacco products. Although the Tobacco Control Act prohibits FDA 

from banning the sale of cigarettes, it does authorize the 

agency to set standards for tobacco products that could 

significantly impact the marketing of tobacco products. 

Specifically, the act allows FDA to issue a product standard 

to prohibit menthol in cigarettes, or any other tobacco 

product, to protect public health. Moreover, the Tobacco 

Table 8.2 Potential end-game strategies discussed in the 50th anniversary Surgeon General’s report, 2014

Potential end-game strategy Description

Reduce nicotine yield in cigarettes and other tobacco products Use government regulations to gradually reduce the level of 

nicotine in cigarettes, and possibly other tobacco products, 

to nonaddictive levels 

Reduce toxicity in tobacco products Implement regulatory standards that require manufacturers 

to create tobacco products with very low toxicity

Gradually reduce the supply of tobacco products Phase out over time the use of tobacco products via systematic 

reduction of supply to zero or to some other minimal level 

Prohibit the sale of tobacco products to future generations Prohibit the sale of tobacco products to persons born after a 

specific date, essentially creating tobacco-free cohorts that 

progressively increase in coverage and size over time

Prohibit cigarettes and/or cigarettes and other tobacco products Prohibit the production and sale of cigarettes and possibly 

other types of tobacco products

Sell tobacco products through a not-for-profit agency Transfer control of the supply and sales of tobacco products to a 

not-for-profit agency that has the goal of reducing consumption

Sources: Benowitz and Henningfield 1994, 2013; Borland 2003, 2013; Callard et al. 2005a,b; Daynard et al. 2010; Hatsukami et al. 2010, 

2012, 2013; Khoo et al. 2010; Thomson et al. 2010; Proctor 2011, 2013; Berrick 2013; Callard and Collishaw 2013; Wilson et al. 2013; 

USDHHS 2014.
A Vision for the Future 655

Smoking Cessation

Control Act does not preempt states and localities from 

prohibiting the sale of cigarettes or other tobacco products. However, other factors may preclude such actions, 

including state constitutions or other state laws, which 

could prevent the implementation of such measures at 

the local level. Additionally, prohibiting specific types of 

tobacco products (e.g., flavored tobacco products) could 

also impact population-level cessation. In November 2018, 

FDA indicated its intent to prohibit menthol in combustible tobacco products, prohibit flavored cigars, and prohibit flavored e-cigarettes (excluding tobacco and menthol flavors), except those sold in age-restricted, in-person 

locations (FDA 2018b). Several jurisdictions in California, 

Illinois, Massachusetts, Minnesota, New York, and Rhode 

Island have restricted the sale of flavored tobacco products, 

with some of these policies not exempting menthol flavors 

(Campaign for Tobacco-Free Kids 2019). Prohibiting flavors, including menthol, in tobacco products can benefit 

public health by reducing initiation among young people 

and promoting cessation among adults (USDHHS 2014). 

For example, studies show that a sizable portion of adults 

who smoke menthol cigarettes report that they would try 

to quit smoking if menthol cigarettes were prohibited 

(O’Connor et al. 2012; Pearson et al. 2012). In 2011, the 

Tobacco Product Scientific Advisory Committee (TPSAC) 

to the FDA conducted an extensive review of the state of 

the science on menthol, concluding that the “[r]emoval 

of menthol cigarettes from the marketplace would benefit 

public health in the United States” (TPSAC 2011, p. 225). 

Furthermore, FDA conducted a subsequent independent 

review of the science and concluded, “From the available studies, the weight of evidence supports the conclusion that menthol in cigarettes is likely associated with 

reduced success in smoking cessation, especially among 

African American menthol smokers” (FDA n.d., p. 6).

But end-game strategies cannot function in isolation and should not be seen as a panacea or as a substitute for the accelerated implementation of established 

population-based strategies. To that end, an integrated 

national tobacco control strategy is essential—one that is 

based on a foundation of enhanced implementation of the 

traditional strategies that have been shown to be effective, 

including taxation, smokefree policies, barrier-free cessation support, and hard-hitting mass media campaigns 

(USDHHS 2014; King and Graffunder 2018). The most 

feasible end-game strategies—such as reducing the nicotine content in cigarettes to make them less addictive and 

placing greater restrictions on sales of tobacco products, 

including prohibitions on entire categories of tobacco 

products—could then be integrated into this foundational 

platform (Van der Eijk 2015). Using this paradigm, a more 

aggressive implementation of the proven populationbased interventions outlined in Chapter 7 would reinforce 

cessation efforts nationally and enhance the feasibility and 

impact of end-game strategies.

The pursuit of an integrated strategy of accelerated implementation of proven interventions coupled 

with the introduction of novel end-game interventions is 

likely to encounter unique challenges (Isett 2013; Rabe 

2013; Thomas and Gostin 2013). These challenges are 

likely to come from two key groups. The first group is 

those with a financial stake in the continued widespread 

use of cigarettes and other tobacco products, including 

the traditional tobacco industry and the emerging array of 

e-cigarette companies and related entities advocating for

their interests (USDHHS 2014). The tobacco industry has

an extensive history of attempting to influence decision

makers to oppose evidence-based tobacco control strategies, and because local control is so integral to galvanizing evidence-based policies and shifting social norms,

the tobacco industry and its allies have used strategies to

preempt local smokefree laws and other types of tobacco

control policies (USDHHS 2014). The second group is

users of tobacco products and others who would be ideologically opposed to any policy or strategy that would

jeopardize the availability and sale of cigarettes and other

tobacco products and the ability of adults to obtain and

consume these products (USDHHS 2014). However, innovation spurred by the proliferation of subnational policies has been a hallmark of tobacco control for decades,

at times giving rise to approaches that have been emulated by practitioners in other disciplines. As noted in the

50th anniversary Surgeon General’s report, “It is important to remember that many policy innovations, once

thought inconceivable, have now become the law of the

land” (USDHHS 2014, p.  858). Just two decades ago,

it  would have been difficult to envision that more than

half of U.S. states and more than 1,000  communities

would be covered by comprehensive smokefree laws, and

even a decade ago, most public health experts would not

have predicted that more than a dozen states and several

hundred communities would increase the legal age of sale

for tobacco to 21  years of age (CDC 2018). Indeed, the

profound and dynamic history of tobacco control over

more than 50  years suggests that continued innovation

is a key tenet of success. Therefore, the public health

community must remain nimble and capable of evolving

as quickly as the rapidly changing landscape of tobacco

products. New developments and innovations will continue to occur, as has been the case for decades, but the

public health community need not reinvent the wheel.

Proven interventions can continue to be modernized with

time. Additionally, new end-game strategies offer unprecedented opportunities to complement these interventions to end the epidemic of disease and premature death

caused by tobacco use.
A Report of the Surgeon General

656 Chapter 8

Advancing Cessation

As documented in Chapter 6, a comprehensive body 

of scientific evidence, which has grown stronger over time, 

supports the use of behavioral counseling and pharmacologic interventions for smoking cessation, with the combination of both being the most effective approach. Effective 

counseling interventions include an array of behavioral 

treatments that can be delivered effectively by a variety of 

qualified personnel in many formats, including individual, 

group, and telephone counseling. Additionally, emerging 

evidence suggests that text messaging and web interventions are also effective modalities for delivering cessation 

behavioral interventions. As documented in Chapter  5, 

strong evidence exists for the cost-effectiveness of both 

behavioral and pharmacologic tobacco cessation treatments. However, although more than half of current 

smokers try to quit each year, the success rate of these quit 

attempts remains low, and successful cessation is typically 

preceded by multiple prior attempts (Babb et  al. 2017). 

Moreover, despite gains over the past three decades, both 

the reach and use of existing smoking cessation interventions also remain low, with less than one-third of smokers 

using behavioral and/or pharmacologic interventions when 

trying to quit. The current state of the cessation landscape 

in the United States underscores the fact that more can 

and should be done to help smokers quit for good.

Two factors drive the rate of cessation in the population: the rate of quit attempts and the rate of successful cessation among smokers who try to quit. Thus, 

increases in quit attempts and quit success rates can each 

drive increases in population-level cessation. Moreover, 

increasing the reach and intensity of cessation interventions can each increase the cessation rate in the population (CDC 2014). Of note, some strategies address only 

one of these factors, and others address both. For example, 

a mass media campaign can motivate more smokers to 

try to quit, and the development of a new, more effective 

cessation medication can increase the success rate for 

smokers who try to quit. In contrast, a mass media campaign that drives smokers to a quitline or a promotional 

campaign that drives smokers enrolled in Medicaid to 

take advantage of newly improved Medicaid cessation coverage in their state can (a) motivate more smokers to try 

to quit and (b) by connecting these smokers with proven 

cessation treatments, increase their chances of quitting 

successfully. Therefore, strategies that increase the rate 

of quit attempts and the rate of successful cessation are 

especially important.

As noted in this report, increasing quit rates requires 

several strategies that include increasing the appeal and 

reach of existing evidence-based interventions to smokers. 

Promising directions to increase appeal and reach could 

include expanding treatment targets, leveraging emerging 

technologies to enhance the initial and sustained engagement of smokers in treatment, and accelerating the integration of cessation services across multiple platforms and 

in healthcare systems. Given shifts in the manner in which 

people communicate and obtain information, possible 

emerging technologies that could be considered include 

(a) mobile health platforms with applications that involve 

adaptive interventions that are tailored to the needs of 

each person and (b) social media and other applications 

that deliver behavioral treatment and improve adherence 

to medication.

In addition to enhancing the reach of behavioral 

support, the enhanced availability of generic versions of 

FDA-approved brand-name drugs could enhance access 

to and the reach of these medications, particularly with 

regard to increased affordability among persons in lower 

socioeconomic groups, who traditionally have high rates 

of smoking (Wang et al. 2018). It is anticipated that health 

insurers would be more likely to cover generic cessation 

medications with no or minimal barriers because generic 

medications are typically less expensive; this would 

increase the affordability of and access to these medications among smokers, especially low-income smokers. 

Additionally, Leischow (2019) proposed enhancing access 

to and the reach of proven pharmacotherapies by making 

varenicline and other prescription medications for 

smoking cessation available over the counter. The conversion of pharmacotherapies to over-the-counter medicines 

requires careful weighing of risks and benefits at the individual and population levels.

Increasing quit rates could also be achieved by 

increasing the effectiveness of existing interventions. 

Chapter 6 of this report concluded, “The evidence is sufficient to infer that combining short- and long-acting 

forms of nicotine replacement therapy increases smoking 

cessation compared with using single forms of nicotine 

replacement therapy.” Emerging evidence also suggests 

that combining varenicline with bupropion or NRT may 

be more effective than taking varenicline alone, particularly among heavy smokers. In addition, combination 

therapy involving bupropion and NRT has been shown to 

produce better outcomes than either medication used by 

itself. Reaching a better understanding of both behavioral 

and pharmacological interventions that can safely and 

effectively promote cessation among youth is becoming 

increasingly important because of the dearth of evidence 

on this issue and because of recent surges in e-cigarette 

use and frequency among youth, particularly products 

that utilize nicotine salts (USDHHS 2018).

Efforts can also be made to increase quit rates 

through the development of cessation interventions that 

have greater reach and/or effectiveness than existing 
A Vision for the Future 657

Smoking Cessation

interventions or that appeal to and are used by different populations of smokers. For example, according 

to this report, evidence is suggestive but not sufficient 

to conclude that cytisine is effective for smoking cessation (Chapter 6). Cytisine is used for cessation in several 

Eastern European countries but is not yet approved by 

FDA for use as a cessation medication in the United States. 

More research is needed to further assess the safety and 

efficacy of cytisine for smoking cessation and its possible 

utility in the United States.

Similarly, more research is needed on the potential 

of using e-cigarettes as a smoking cessation aid, including 

determining what types of e-cigarettes and what aspects 

of use may maximize positive cessation outcomes and 

minimize adverse consequences, especially related to use 

among young people. Chapter 6 of this report concluded 

that the evidence is inadequate to infer that e-cigarettes, 

in general, increase smoking cessation. It also concluded 

that the evidence is suggestive but not sufficient to infer 

that the use of e-cigarettes containing nicotine is associated with increased smoking cessation compared with the 

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

frequent use of e-cigarettes is associated with increased 

smoking cessation compared with less frequent use of 

e-cigarettes. It is also important to note that the e-cigarette 

landscape continues to evolve, and existing research has

not assessed newer types of e-cigarettes, including those

that use nicotine salts. Such products may deliver nicotine content more efficiently and, therefore, may be more

effective for smoking cessation than earlier generations of

e-cigarettes. However, this formulation could also make it

more difficult for those who fully transition to e-cigarettes

to eventually quit using these products completely.

The aforementioned individual treatments for 

smoking cessation are necessary but not sufficient to 

fully achieve meaningful population-based cessation outcomes. As discussed in Chapter 7, these interventions are 

most effective when complemented by actions taken at the 

clinical and health systems levels to create environments 

that support the use of cessation treatments and successful cessation by smokers—including policies to transform systems of care to better address tobacco use and 

dependence, the promotion of evidence-based treatments 

for tobacco use and dependence, and the implementation of policies (e.g., covering all evidence-based cessation treatments; removing barriers to treatments, such as 

prior authorization; and promoting covered treatments to 

smokers and providers so that they are aware of and use 

these treatments) to increase smokers’ access to clinical 

interventions and cessation treatments that could help 

them quit. Although considerable progress has been made 

to integrate nicotine dependence treatment into clinical 

health systems over the past several decades, substantial 

opportunities for improvement remain, for example: 

• Embedding policies and protocols for tobacco

use screening and interventions into the clinical

workflow;

• Embedding prompts, decision support, and documentation tools into health records, including electronic health records; and

• Distributing specific components of the intervention across the broader healthcare team to reduce

the burden on time-constrained physicians and to

reinforce the importance of cessation to patients.

Because cigarette smoking remains high and quitting smoking may be more difficult among certain subpopulations in the United States, including persons of 

lower socioeconomic status and those with comorbid 

mental health and other substance use disorders (Wang 

et al. 2018), specific types of healthcare providers or clinical environments could become increasingly important 

in promoting cessation and delivering targeted cessation support. In addition to policies that seek to make the 

delivery of clinical cessation interventions in health systems more consistent and routine, policies that remove 

cost and other barriers to access for patients are also 

essential to increase the delivery and utilization of nicotine dependence treatment, especially when barrier-free 

coverage is well promoted to health plan beneficiaries. 

Timely and relevant clinical guidelines and clinical quality 

measures also play critical roles in ensuring that clinicians 

and staff from healthcare systems intervene consistently 

with tobacco users. Improving and promoting insurance coverage of treatment for tobacco use and dependence are also essential. Cessation benefits should cover 

all evidence-based cessation interventions, including brief 

and intensive counseling and all FDA-approved medications, including combination NRT therapy. This coverage 

should be provided with no or minimal barriers, such 

as prior authorization, duration limits, or cost-sharing. 

Regardless of how well designed a coverage benefit may 

be, coverage alone, without promotion, is not sufficient. 

Benefits for smoking cessation, whether offered through a 

health insurer or an employee wellness program, must be 

promoted to increase awareness.

In addition to the individual and clinical health systems interventions cited previously, population-based 

policy and program actions also serve critical roles in 

broadly influencing the behavior of smokers as they try 

to quit or think about quitting smoking. As noted in 

Chapter  7, population-level policy and program actions 
A Report of the Surgeon General

658 Chapter 8

can facilitate the integration of individual treatments into 

routine clinical care, thus making cessation interventions available and accessible to individual smokers and 

motivating smokers to use them. Such actions can occur 

at multiple levels—national, state, and local—and may 

involve government and nongovernment entities. These 

policies and programs include quitlines, which are an 

evidence-based, population-level strategy to increase the 

accessibility and uptake of scientifically proven cessation 

support, including the optimal combination of cessation 

counseling and medication.

Tobacco quitlines have typically been funded at 

the state level, but they can also be used by and funded 

through employers, health plans, and health systems. 

Quitlines offer convenient mechanisms through which 

health insurers and employers can partially meet federal requirements for coverage of tobacco cessation and 

reduce tobacco-related health expenditures. Employers 

can offer a tobacco quitline as an employee benefit to promote tobacco cessation and to help increase the productivity of employees who use tobacco by helping them to 

quit. Health systems can use quitlines as a complement 

to clinical care and to provide more intensive follow-up 

to patients engaged in a quit attempt. Provider referrals 

offer a less expensive and potentially more sustainable 

approach to drive smokers to quitline services, although 

developing and maintaining relationships with health systems and putting referral systems in place can be timeand staff-intensive. As described in Chapter  6, quitlines 

are increasingly linked to the delivery of cessation treatment by primary care providers, and enhanced use of 

electronic health records to electronically refer patients 

who smoke to quitlines is warranted. Beyond quitline 

e-referrals, electronic health records can be a critical tool 

for improving the frequency, quality, and consistency of 

screening and treatment for tobacco use and dependence, 

thereby increasing adherence to clinical practice guidelines. However, it is important that careful and intentional efforts must be made to integrate appropriate, evidence-based cessation content into the electronic health 

record system and to make parallel changes to the clinical 

work flow.

Although telephone quitlines are a clinical treatment, they are supported through broad policies at 

the local, state, and national levels and are designed to 

be accessed on a population-wide basis to address quit 

attempts, successful quitting, and the prevalence of 

smoking. Supportive policies include price increases 

(e.g.,  increasing excise taxes); restrictions on where 

tobacco can be used (e.g.,  smokefree policies); adequately funding state programs for tobacco control; carrying out mass media campaigns (e.g., CDC’s Tips From 

Former Smokers campaign [Tips], FDA’s Every Try Counts 

campaign); and developing product regulations, such as 

requiring pictorial health warnings. Additionally, promising policies discussed in Chapter 7 include those focused 

on limiting retail density and point-of-sale tobacco advertising and on policies seeking to regulate the nicotine content in cigarettes to very low, nonaddictive levels.

Population-level policies have a broad impact, can 

change the context and environment to make it easier for 

persons to quit, and are more likely to help people quit 

and stay quit when coupled with clinical interventions at 

the individual level. Specifically, combining clinical and 

health system-based and population-level policy actions 

can improve cessation outcomes. For example, in addition to motivating smokers to make a quit attempt, a mass 

media campaign, such as the Tips campaign and the Every 

Try Counts campaign, can connect smokers to evidencebased resources for cessation treatment, such as a quitline 

or, in some cases, a healthcare provider. Therefore, clinicians and public health practitioners should connect clinical work with macro-level policy work to maximize the 

impact of tobacco-control interventions at the population 

level on tobacco cessation and to facilitate the implementation of these interventions.

Accelerating National Momentum 

to Promote Cessation

As noted in the 50th anniversary Surgeon General’s 

report, the scientific evidence is undeniable: inhaling the 

combusted compounds from tobacco smoke is deadly 

(USDHHS 2014). Although substantial progress has been 

made to reduce smoking in the United States over the past 

five decades, by increasing adult smoking cessation and by 

reducing youth smoking initiation, more can and should 

be done. The following major conclusions from this report 

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

smoking in the United States:

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

smoked cigarettes have quit. Although a majority of 

cigarette smokers make a quit attempt each year, 

less than one-third use FDA-approved cessation 

medications or behavioral counseling to support 

these attempts.

• Smoking places a substantial financial burden on 

smokers, healthcare systems, and society. Smoking 

cessation reduces this burden, including smokingattributable healthcare expenditures.
A Vision for the Future 659

Smoking Cessation

• Considerable disparities exist in the prevalence of

smoking across the U.S. population; such prevalence is higher in some subgroups. Similarly, the

prevalence of key indicators of smoking cessation—

quit attempts, receiving advice to quit from a health

professional, and using cessation therapies—also

varies across the population, with lower prevalence

among some subgroups.

To increase smoking cessation and reduce smoking

in the United States, this report outlines a broad range 

of well-defined and effective population-based interventions that are necessary, at present, to help the 34 million 

American adults who currently smoke cigarettes quit:

• Fully funded, comprehensive statewide tobacco control programs;

• Higher average retail prices of cigarettes—at least

$10 a pack;

• Complete protection of the entire U.S. population

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

restaurants, and bars;

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

From Former Smokers, that run with sufficient reach, 

frequency, and duration—ideally for 12  months a

year; and

• Product regulations, such as requiring pictorial

health warnings.

However, these population-based actions and the

more aggressive use of the evidence-based policies and 

programs reviewed in Chapter 7 are not enough. An array 

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

cessation and treat tobacco use and dependence in the 

United States:

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

integration of cessation services across multiple

platforms and in healthcare systems;

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

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

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

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

for greater reach and/or effectiveness than existing

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

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

that address the diversity of tobacco products being

used by these populations, including e-cigarettes;

• Embedding policies and protocols for tobacco use

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

documentation tools into health records, such as

electronic health records; and distributing specific

components of the intervention across the broader

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

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

policies that remove cost and barriers to access for

patients to increase the delivery and utilization of

tobacco dependence treatment;

• Providing timely and relevant clinical guidelines

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

with tobacco users;

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

cost-sharing, or other barriers that impede smokers’

access to cessation treatments—to increase the

availability and utilization of treatment services for

smoking cessation;

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

evidence-based cessation interventions, including

brief and intensive counseling and all FDA-approved

medications, including combination NRT therapy;

• Promoting cessation coverage and services, whether

offered through a health insurer or an employee

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

treatments; coverage alone, without promotion, is

not sufficient; and
A Report of the Surgeon General

660 Chapter 8

• Adequately funding and promoting tobacco quitlines to enable their operations and services to function at  levels sufficient to maximize their reach 

and impact.

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

combating the tobacco use epidemic in the United States 

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

and disseminating timely, high-quality scientific studies 

on best practices; in modernizing existing interventions 

to keep pace with the rapidly diversifying landscape of 

tobacco products; and in identifying emerging strategies to 

ensure more rapid elimination of the health and economic 

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

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

tobacco use. Strategies that have been proposed include:

• Implementing a tobacco product standard to lower 

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

• Restricting the sale of tobacco products, such as 

prohibitions on entire categories of flavored tobacco 

products, including menthol.

Such actions have the potential to accelerate 

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

the end of the tobacco epidemic. However, these actions 

and the extensive body of evidence-based clinical, health 

system, and population-based tobacco prevention, control, 

and cessation strategies that are outlined in this report 

are a necessary but insufficient means to end the tobacco 

epidemic. Reaching the finish line will require coordination across federal government agencies and other stakeholders at the national, state, and local levels. To achieve 

success, we must work together to maximize resources 

and coordinate efforts across a wide range of stakeholders. 

Stakeholders who have a role to play include federal, state, 

local, tribal, and territorial governments; voluntary health 

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

and healthcare professionals; researchers; and individuals 

(USDHHS 2016). Stakeholders must also continue to hold 

the tobacco industry accountable for its role in creating, 

obscuring, and perpetuating the tobacco use epidemic in 

the United States (USDHHS 2014). For example, beginning in 2017, the major U.S. tobacco companies were 

required by the U.S. District Court for the District of 

Columbia to run “corrective statements” via television and 

newspaper ads and to publish statements on their websites 

and cigarette packs that tell the American public the truth 

about the dangers of smoking and secondhand smoke 

(U.S. Department of Justice 2017; Farber et al. 2018). The 

tobacco control movement has achieved remarkable progress over time through coordinated actions by diverse 

stakeholders. The most effective interventions frequently 

originate at the local level before percolating to higher 

levels and ultimately becoming recognized as evidencebased practices (CDC 2014; USDHHS 2014). Action at 

the federal level is a key lever to success, but such action 

must be complemented by subnational and nongovernmental efforts to continue to denormalize tobacco use and 

advance the strategies that we know work to combat the 

devastating effects of tobacco use on society (USDHHS 

2014). Each stakeholder can make unique and critical 

contributions toward reducing tobacco-related disease 

and death in the United States. In particular, there are 

opportunities for practitioners, experts, and researchers 

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

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

effort to build linkages.

We are at the precipice of a critical period in the 

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

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

an important public health achievement, which has been 

driven in part by increases in adult smoking cessation 

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

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

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

we have the experience and wherewithal to do it. Equipped 

with both science and resolve, we will continue to move 

forward to end the tobacco epidemic in the United States. 

Working together, we can make tobacco-related disease 

and death a thing of the past.
A Vision for the Future 661

Smoking Cessation

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