smoking kills essay

Essay on Smoking

500 words essay on smoking.

One of the most common problems we are facing in today’s world which is killing people is smoking. A lot of people pick up this habit because of stress , personal issues and more. In fact, some even begin showing it off. When someone smokes a cigarette, they not only hurt themselves but everyone around them. It has many ill-effects on the human body which we will go through in the essay on smoking.

Ill-Effects of Smoking

Tobacco can have a disastrous impact on our health. Nonetheless, people consume it daily for a long period of time till it’s too late. Nearly one billion people in the whole world smoke. It is a shocking figure as that 1 billion puts millions of people at risk along with themselves.

Cigarettes have a major impact on the lungs. Around a third of all cancer cases happen due to smoking. For instance, it can affect breathing and causes shortness of breath and coughing. Further, it also increases the risk of respiratory tract infection which ultimately reduces the quality of life.

In addition to these serious health consequences, smoking impacts the well-being of a person as well. It alters the sense of smell and taste. Further, it also reduces the ability to perform physical exercises.

It also hampers your physical appearances like giving yellow teeth and aged skin. You also get a greater risk of depression or anxiety . Smoking also affects our relationship with our family, friends and colleagues.

Most importantly, it is also an expensive habit. In other words, it entails heavy financial costs. Even though some people don’t have money to get by, they waste it on cigarettes because of their addiction.

How to Quit Smoking?

There are many ways through which one can quit smoking. The first one is preparing for the day when you will quit. It is not easy to quit a habit abruptly, so set a date to give yourself time to prepare mentally.

Further, you can also use NRTs for your nicotine dependence. They can reduce your craving and withdrawal symptoms. NRTs like skin patches, chewing gums, lozenges, nasal spray and inhalers can help greatly.

Moreover, you can also consider non-nicotine medications. They require a prescription so it is essential to talk to your doctor to get access to it. Most importantly, seek behavioural support. To tackle your dependence on nicotine, it is essential to get counselling services, self-materials or more to get through this phase.

One can also try alternative therapies if they want to try them. There is no harm in trying as long as you are determined to quit smoking. For instance, filters, smoking deterrents, e-cigarettes, acupuncture, cold laser therapy, yoga and more can work for some people.

Always remember that you cannot quit smoking instantly as it will be bad for you as well. Try cutting down on it and then slowly and steadily give it up altogether.

Get the huge list of more than 500 Essay Topics and Ideas

Conclusion of the Essay on Smoking

Thus, if anyone is a slave to cigarettes, it is essential for them to understand that it is never too late to stop smoking. With the help and a good action plan, anyone can quit it for good. Moreover, the benefits will be evident within a few days of quitting.

FAQ of Essay on Smoking

Question 1: What are the effects of smoking?

Answer 1: Smoking has major effects like cancer, heart disease, stroke, lung diseases, diabetes, and more. It also increases the risk for tuberculosis, certain eye diseases, and problems with the immune system .

Question 2: Why should we avoid smoking?

Answer 2: We must avoid smoking as it can lengthen your life expectancy. Moreover, by not smoking, you decrease your risk of disease which includes lung cancer, throat cancer, heart disease, high blood pressure, and more.

Customize your course in 30 seconds

Which class are you in.

Travelling Essay
Picnic Essay
Our Country Essay
My Parents Essay
Essay on Favourite Personality
Essay on Memorable Day of My Life
Essay on Knowledge is Power
Essay on Gurpurab
Essay on My Favourite Season
Essay on Types of Sports

Download the App

Persuasive Essay Guide

Persuasive Essay About Smoking

Persuasive Essay About Smoking - Making a Powerful Argument with Examples

What You Need To Know About Persuasive Essay

A persuasive essay is a type of writing that aims to convince its readers to take a certain stance or action. It often uses logical arguments and evidence to back up its argument in order to persuade readers.

It also utilizes rhetorical techniques such as ethos, pathos, and logos to make the argument more convincing. In other words, persuasive essays use facts and evidence as well as emotion to make their points.

A persuasive essay about smoking would use these techniques to convince its readers about any point about smoking. Check out an example below:

Simple persuasive essay about smoking

Tough Essay Due? Hire Tough Writers!

Persuasive Essay Examples About Smoking

Smoking is one of the leading causes of preventable death in the world. It leads to adverse health effects, including lung cancer, heart disease, and damage to the respiratory tract. However, the number of people who smoke cigarettes has been on the rise globally.

A lot has been written on topics related to the effects of smoking. Reading essays about it can help you get an idea of what makes a good persuasive essay.

Here are some sample persuasive essays about smoking that you can use as inspiration for your own writing:

Persuasive speech on smoking outline

Persuasive essay about smoking should be banned

Persuasive essay about smoking pdf

Persuasive essay about smoking cannot relieve stress

Persuasive essay about smoking in public places

Speech about smoking is dangerous

Persuasive Essay About Smoking Introduction

Persuasive Essay About Stop Smoking

Short Persuasive Essay About Smoking

Stop Smoking Persuasive Speech

Check out some more persuasive essay examples on various other topics.

Argumentative Essay About Smoking Examples

An argumentative essay is a type of essay that uses facts and logical arguments to back up a point. It is similar to a persuasive essay but differs in that it utilizes more evidence than emotion.

If you’re looking to write an argumentative essay about smoking, here are some examples to get you started on the arguments of why you should not smoke.

Argumentative essay about smoking pdf

Argumentative essay about smoking in public places

Argumentative essay about smoking introduction

Check out the video below to find useful arguments against smoking:

Tips for Writing a Persuasive Essay About Smoking

You have read some examples of persuasive and argumentative essays about smoking. Now here are some tips that will help you craft a powerful essay on this topic.

Choose a Specific Angle

Select a particular perspective on the issue that you can use to form your argument. When talking about smoking, you can focus on any aspect such as the health risks, economic costs, or environmental impact.

Think about how you want to approach the topic. For instance, you could write about why smoking should be banned.

Check out the list of persuasive essay topics to help you while you are thinking of an angle to choose!

Research the Facts

Before writing your essay, make sure to research the facts about smoking. This will give you reliable information to use in your arguments and evidence for why people should avoid smoking.

You can find and use credible data and information from reputable sources such as government websites, health organizations, and scientific studies.

For instance, you should gather facts about health issues and negative effects of tobacco if arguing against smoking. Moreover, you should use and cite sources carefully.

Paper Due? Why Suffer? That's our Job!

Make an Outline

The next step is to create an outline for your essay. This will help you organize your thoughts and make sure that all the points in your essay flow together logically.

Your outline should include the introduction, body paragraphs, and conclusion. This will help ensure that your essay has a clear structure and argument.

Use Persuasive Language

When writing your essay, make sure to use persuasive language such as “it is necessary” or “people must be aware”. This will help you convey your message more effectively and emphasize the importance of your point.

Also, don’t forget to use rhetorical devices such as ethos, pathos, and logos to make your arguments more convincing. That is, you should incorporate emotion, personal experience, and logic into your arguments.

Introduce Opposing Arguments

Another important tip when writing a persuasive essay on smoking is to introduce opposing arguments. It will show that you are aware of the counterarguments and can provide evidence to refute them. This will help you strengthen your argument.

By doing this, your essay will come off as more balanced and objective, making it more convincing.

Finish Strong

Finally, make sure to finish your essay with a powerful conclusion. This will help you leave a lasting impression on your readers and reinforce the main points of your argument. You can end by summarizing the key points or giving some advice to the reader.

A powerful conclusion could either include food for thought or a call to action. So be sure to use persuasive language and make your conclusion strong.

To conclude,

By following these tips, you can write an effective and persuasive essay on smoking. Remember to research the facts, make an outline, and use persuasive language.

However, don't stress if you need expert help to write your essay! Our professional essay writing service is here for you!

Our persuasive essay writing service is fast, affordable, and trustworthy.

Try it out today!

Write Essay Within 60 Seconds!

Caleb S. has been providing writing services for over five years and has a Masters degree from Oxford University. He is an expert in his craft and takes great pride in helping students achieve their academic goals. Caleb is a dedicated professional who always puts his clients first.

Paper Due? Why Suffer? That’s our Job!

Keep reading

235 Smoking Essay Topics & Examples

Looking for smoking essay topics? Being one of the most serious psychological and social issues, smoking is definitely worth writing about.

🏆 Best Smoking Essay Examples & Topic Ideas

🥇 good titles for smoking essay, 👍 best titles for research paper about smoking, ⭐ simple & easy health essay titles, 💡 interesting topics to write about health, ❓ essay questions about smoking.

In your essay about smoking, you might want to focus on its causes and effects or discuss why smoking is a dangerous habit. Other options are to talk about smoking prevention or to concentrate on the reasons why it is so difficult to stop smoking. Here we’ve gathered a range of catchy titles for research papers about smoking together with smoking essay examples. Get inspired with us!

Smoking is a well-known source of harm yet popular regardless, and so smoking essays should cover various aspects of the topic to identify the reasons behind the trend.

You will want to discuss the causes and effects of smoking and how they contributed to the persistent refusal of large parts of the population to abandon the habit, even if they are aware of the dangers of cigarettes. You should provide examples of how one may become addicted to tobacco and give the rationales for smokers.

You should also discuss the various consequences of cigarette use, such as lung cancer, and identify their relationship with the habit. By discussing both sides of the issue, you will be able to write an excellent essay.

Reasons why one may begin smoking, are among the most prominent smoking essay topics. It is not easy to begin to enjoy the habit, as the act of smoke inhalation can be difficult to control due to a lack of experience and unfamiliarity with the concept.

As such, people have to be convinced that the habit deserves consideration by various ideas or influences. The notion that “smoking is cool” among teenagers can contribute to the adoption of the trait, as can peer pressure.

If you can find polls and statistics on the primary factors that lead people to tweet, they will be helpful to your point. Factual data will identify the importance of each cause clearly, although you should be careful about bias.

The harmful effects of tobacco have been researched considerably more, with a large body of medical studies investigating the issue available to anyone.

Lung cancer is the foremost issue in the public mind because of the general worry associated with the condition and its often incurable nature, but smoking can lead to other severe illnesses.

Heart conditions remain a prominent consideration due to their lethal effects, and strokes or asthma deserve significant consideration, as well. Overall, smoking has few to no beneficial health effects but puts the user at risk of a variety of concerns.

As such, people should eventually quit once their health declines, but their refusal to do so deserves a separate investigation and can provide many interesting smoking essay titles.

One of the most prominent reasons why a person would continue smoking despite all the evidence of its dangers and the informational campaigns carried out to inform consumers is nicotine addiction.

The substance is capable of causing dependency, a trait that has led to numerous discussions of the lawfulness of the current state of cigarettes.

It is also among the most dangerous aspects of smoking, a fact you should mention.

Lastly, you can discuss the topics of alternatives to smoking in your smoking essay bodies, such as e-cigarettes, hookahs, and vapes, all of which still contain nicotine and can, therefore, lead to considerable harm. You may also want to discuss safe cigarette avoidance options and their issues.

Here are some additional tips for your essay:

Dependency is not the sole factor in cigarette consumption, and many make the choice that you should respect consciously.
Cite the latest medical research titles, as some past claims have been debunked and are no longer valid.
Mortality is not the sole indicator of the issues associated with smoking, and you should take chronic conditions into consideration.

Find smoking essay samples and other useful paper samples on IvyPanda, where we have a collection of professionally written materials!

Conclusion of Smoking Should Be Banned on College Campuses Essay However, it is hard to impose such a ban in some colleges because of the mixed reactions that are held by different stakeholders about the issue of smoking, and the existing campus policies which give […]
Should Smoking Be Banned in Public Places? Besides, smoking is an environmental hazard as much of the content in the cigarette contains chemicals and hydrocarbons that are considered to be dangerous to both life and environment.
Smoking: Problems and Solutions To solve the problem, I would impose laws that restrict adults from smoking in the presence of children. In recognition of the problems that tobacco causes in the country, The Canadian government has taken steps […]
How Smoking Is Harmful to Your Health The primary purpose of the present speech is to inform the audience about the detrimental effects of smoking. The first system of the human body that suffers from cigarettes is the cardiovascular system.
Causes and Effects of Smoking Some people continue smoking as a result of the psychological addiction that is associated with nicotine that is present in cigarettes.
Smoking Cigarette Should Be Banned Ban on tobacco smoking has resulted to a decline in the number of smokers as the world is sensitized on the consequences incurred on 31st May.
On Why One Should Stop Smoking Thesis and preview: today I am privileged to have your audience and I intend to talk to you about the effects of smoking, and also I propose to give a talk on how to solve […]
Smoking: Effects, Reasons and Solutions This presentation provides harmful health effects of smoking, reasons for smoking, and solutions to smoking. Combination therapy that engages the drug Zyban, the concurrent using of NRT and counseling of smokers under smoking cessation program […]
Advertisements on the Effect of Smoking Do not Smoke” the campaign was meant to discourage the act of smoking among the youngsters, and to encourage them to think beyond and see the repercussions of smoking.
Smoking and Its Negative Effects on Human Beings Therefore, people need to be made aware of dental and other health problems they are likely to experience as a result of smoking.
Smoking Cessation Programs Through the Wheel of Community Organizing The first step of the wheel is to listen to the community’s members and trying to understand their needs. After the organizer and the person receiving treatment make the connection, they need to understand how […]
Smoking Among Teenagers as Highlighted in Articles The use of tobacco through smoking is a trend among adolescents and teenagers with the number of young people who involve themselves in smoking is growing each day.
Causes and Effects of Smoking in Public The research has further indicated that the carcinogens are in higher concentrations in the second hand smoke rather than in the mainstream smoke which makes it more harmful for people to smoke publicly.
“Thank You For Smoking” by Jason Reitman Film Analysis Despite the fact that by the end of the film the character changes his job, his nature remains the same: he believes himself to be born to talk and convince people.
Health Promotion Plan: Smokers in Mississippi The main strategies of the training session are to reduce the number of smokers in Mississippi, conduct a training program on the dangers of smoking and work with tobacco producers.
Public Health Education: Anti-smoking Project The workshop initiative aimed to achieve the following objectives: To assess the issues related to smoking and tobacco use. To enhance the health advantages of clean air spaces.
Summary of “Smokers Get a Raw Deal” by Stanley Scott Lafayette explains that people who make laws and influence other people to exercise these laws are obviously at the top of the ladder and should be able to understand the difference between the harm sugar […]
Smoking and Youth Culture in Germany The report also assailed the Federal Government for siding the interest of the cigarette industry instead of the health of the citizens.
Introducing Smoking Cessation Program: 5 A’s Intervention Plan The second problem arises in an attempt to solve the issue of the lack of counseling in the unit by referring patients to the outpatient counseling center post-hospital discharge to continue the cessation program.
Teenage Smoking and Solution to This Problem Overall, the attempts made by anti-smoking campaigners hardly yield any results, because they mostly focus on harmfulness of tobacco smoking and the publics’ awareness of the problem, itself, but they do not eradicate the underlying […]
Smoking and Its Effects on Human Body The investigators explain the effects of smoking on the breath as follows: the rapid pulse rate of smokers decreases the stroke volume during rest since the venous return is not affected and the ventricles lose […]
Tobacco Debates in “Thank You for Smoking” The advantage of Nick’s strategy is that it offers the consumer a role model to follow: if smoking is considered to be ‘cool’, more people, especially young ones, will try to become ‘cool’ using cigarettes.
Smoking Habit, Its Causes and Effects Smoking is one of the factors that are considered the leading causes of several health problems in the current society. Smoking is a habit that may be easy to start, but getting out of this […]
Ban Smoking in Cars Out of this need, several regulations have been put in place to ensure children’s safety in vehicles is guaranteed; thus, protection from second-hand smoke is an obvious measure that is directed towards the overall safety […]
Aspects of Anti-Smoking Advertising Thus, it is safe to say that the authors’ main and intended audience is the creators of anti-smoking public health advertisements.
Smoking Qualitative Research: Critical Analysis Qualitative research allows researchers to explore a wide array of dimensions of the social world, including the texture and weave of everyday life, the understandings, experiences and imaginings of our research participants, the way that […]
The Change of my Smoking Behavior With the above understanding of my social class and peer friends, I was able to create a plan to avoid them in the instances that they were smoking.
Hookah Smoking and Its Risks The third component of a hookah is the hose. This is located at the bottom of the hookah and acts as a base.
Health Promotion for Smokers The purpose of this paper is to show the negative health complications that stem from tobacco use, more specifically coronary heart disease, and how the health belief model can help healthcare professionals emphasize the importance […]
Gender-Based Assessment of Cigarette Smoking Harm Thus, the following hypothesis is tested: Women are more likely than men to believe that smoking is more harmful to health.
Hazards of Smoking and Benefits of Cessation Prabhat Jha is the author of the article “The Hazards of Smoking and the Benefits of Cessation,” published in a not-for-profit scientific journal, eLife, in 2020.
The Impact of Warning Labels on Cigarette Smoking The regulations requiring tobacco companies to include warning labels are founded on the need to reduce nicotine intake, limit cigarette dependence, and mitigate the adverse effects associated with addiction to smoking.
Psilocybin as a Smoking Addiction Remedy Additionally, the biotech company hopes to seek approval from FDA for psilocybin-based therapy treatment as a cigarette smoking addiction long-term remedy.
Tobacco Smoking: The Health Outcomes Tobacco smoke passing through the upper respiratory tract irritates the membrane of the nasopharynx, and other organism parts, generating copious separation of mucus and saliva.
Investing Savings from Quitting Smoking: A Financial Analysis The progression of interest is approximately $50 per year, and if we assume n equal to 45 using the formula of the first n-terms of the arithmetic progression, then it comes out to about 105 […]
Smoking as a Community Issue: The Influence of Smoking A review of the literature shows the use of tobacco declined between 1980 and 2012, but the number of people using tobacco in the world is increasing because of the rise in the global population.
Smoking Public Education Campaign Assessment The major influence of the real cost campaign was to prevent the initiation of smoking among the youth and prevent the prevalence of lifelong smokers.
Smoking Cessation Therapy: Effectiveness of Electronic Cigarettes Based on the practical experiments, the changes in the patients’ vascular health using nicotine and electronic cigarettes are improved within one-month time period. The usage only of electronic cigarettes is efficient compared to when people […]
Quitting Smoking and Related Health Benefits The regeneration of the lungs will begin: the process will touch the cells called acini, from which the mucous membrane is built. Therefore, quitting the habit of smoking a person can radically change his life […]
Smoking and Stress Among Veterans The topic is significant to explore because of the misconception that smoking can alleviate the emotional burden of stress and anxiety when in reality, it has an exacerbating effect on emotional stress.
Smoking as a Predictor of Underachievement By comparing two groups smoking and non-smoking adolescents through a parametric t-test, it is possible to examine this assumption and draw conclusions based on the resulting p-value.
Smoking and the Pandemic in West Virginia In this case, the use of the income variable is an additional facet of the hypothesis described, allowing us to evaluate whether there is any divergence in trends between the rich and the poor.
Anti-Smoking Policy in Australia and the US The anti-smoking policy is to discourage people from smoking through various means and promotion of a healthy lifestyle, as well as to prevent the spread of the desire to smoke.
Smoking Prevalence in Bankstown, Australia The secondary objective of the project was to gather and analyze a sufficient amount of auxiliary scholarly sources on smoking cessation initiatives and smoking prevalence in Australia.
Drug Addiction in Teenagers: Smoking and Other Lifestyles In the first part of this assignment, the health problem of drug addiction was considered among teens and the most vulnerable group was established.
Anti-Smoking Communication Campaign’s Analysis Defining the target audience for an anti-smoking campaign is complicated by the different layers of adherence to the issue of the general audience of young adults.
Smoking as a Risk Factor for Lung Cancer Lung cancer is one of the most frequent types of the condition, and with the low recovery rates. If the problem is detected early and the malignant cells are contained to a small region, surgery […]
Smoking Cessation Project Implementation In addition, the review will include the strengths and weaknesses of the evidence presented in the literature while identifying gaps and limitations.
Smoking Cessation and Health Promotion Plan Patients addicted to tobacco are one of the major concerns of up-to-date medicine as constant nicotine intake leads to various disorders and worsens the health state and life quality of the users.
Maternal and Infant Health: Smoking Prevention Strategies It is known that many women know the dangers of smoking when pregnant and they always try to quit smoking to protect the lives of themselves and the child.
A Peer Intervention Program to Reduce Smoking Rates Among LGBTQ Therefore, the presumed results of the project are its introduction into the health care system, which will promote a healthy lifestyle and diminish the level of smoking among LGBTQ people in the SESLHD.
Tackling Teenage Smoking in Community The study of the problem should be comprehensive and should not be limited by the medical aspect of the issue. The study of the psychological factor is aimed at identifying the behavioral characteristics of smoking […]
Peer Pressure and Smoking Influence on Teenagers The study results indicate that teenagers understand the health and social implications of smoking, but peer pressure contributes to the activity’s uptake.
Smoking: Benefits or Harms? Hundreds of smokers every day are looking for a way to get rid of the noose, which is a yoke around the neck, a cigarette.
The Culture of Smoking Changed in Poland In the 1980-90s, Poland faced the challenge of being a country with the highest rates of smoking, associated lung cancer, and premature mortality in the world.
The Stop Smoking Movement Analysis The paper discusses the ideology, objective, characteristics, context, special techniques, organization culture, target audience, media strategies, audience reaction, counter-propaganda and the effectiveness of the “Stop Smoking” Movement.”The Stop Smoking” campaign is a prevalent example of […]
Smoking Health Problem Assessment The effects of smoking correlate starkly with the symptoms and diseases in the nursing practice, working as evidence of the smoking’s impact on human health.
Integration of Smoking Cessation Into Daily Nursing Practice Generally, smoking cessation refers to a process structured to help a person to discontinue inhaling smoked substances. It can also be referred to as quitting smoking.
E-Cigarettes and Smoking Cessation Many people argue that e-cigarettes do not produce secondhand smoke. They believe that the e-fluids contained in such cigarettes produce vapor and not smoke.
Outdoor Smoking Ban in Public Areas of the Community These statistics have contributed to the widespread efforts to educate the public regarding the need to quit smoking. However, most of the chronic smokers ignore the ramifications of the habit despite the deterioration of their […]
Nicotine Replacement Therapy for Adult Smokers With a Psychiatric Disorder The qualitative research methodology underlines the issue of the lack of relevant findings in the field of nicotine replacement therapy in people and the necessity of treatment, especially in the early stages of implementation.
Smoking and Drinking: Age Factor in the US As smoking and drinking behavior were both strongly related to age, it could be the case that the observed relationship is due to the fact that older pupils were more likely to smoke and drink […]
Poland’s Smoking Culture From Nursing Perspective Per Kinder, the nation’s status as one of Europe’s largest tobacco producers and the overall increase in smoking across the developing nations of Central and Eastern Europe caused its massive tobacco consumption issues.
Smoking Cessation Clinic Analysis The main aim of this project is to establish a smoking cessation clinic that will guide smoker through the process of quitting smoking.
Cigarette Smoking Among Teenagers in the Baltimore Community, Maryland The paper uses the Baltimore community in Maryland as the area to focus the event of creating awareness of cigarette smoking among the teens of this community.
Advocating for Smoking Cessation: Health Professional Role Health professionals can contribute significantly to tobacco control in Australia and the health of the community by providing opportunities for smoking patients to quit smoking.
Lifestyle Management While Quitting Smoking Realistically, not all of the set goals can be achieved; this is due to laxity in implementing them and the associated difficulty in letting go of the past lifestyle.
Smoking in the Actuality The current use of aggressive marketing and advertising strategies has continued to support the smoking of e-cigarettes. The study has also indicated that “the use of such e-cigarettes may contribute to the normalization of smoking”.
Analysis of the Family Smoking Prevention and Tobacco Control Act The law ensures that the FDA has the power to tackle issues of interest to the public such as the use of tobacco by minors.
“50-Year Trends in Smoking-Related Mortality in the United States” by Thun et al. Thun is affiliated with the American Cancer Society, but his research interests cover several areas. Carter is affiliated with the American Cancer Society, Epidemiology Research Program.
Pulmonology: Emphysema Caused by Smoking The further development of emphysema in CH can lead to such complications caused by described pathological processes as pneumothorax that is associated with the air surrounding the lungs.
Smoking and Lung Cancer Among African Americans Primarily, the research paper provides insight on the significance of the issue to the African Americans and the community health nurses.
Health Promotion and Smoking Cessation I will also complete a wide range of activities in an attempt to support the agency’s goals. As well, new studies will be conducted in order to support the proposed programs.
Maternal Mental Health and Prenatal Smoking It was important to determine the variables that may lead to postpartum relapse or a relapse during the period of pregnancy. It is important to note that the findings are also consistent with the popular […]
Nursing Interventions for Smoking Cessation For instance, the authors are able to recognize the need to classify the level of intensity in respect to the intervention that is employed by nurses towards smoking cessation.
Smoking and Cancer in the United States In this research study, data on tobacco smoking and cancer prevalence in the United States was used to determine whether cancer in the United States is related to tobacco smoking tobacco.
Marketing Plan: Creating a Smoking Cessation Program for Newton Healthcare Center The fourth objective is to integrate a smoking cessation program that covers the diagnosis of smoking, counseling of smokers, and patient care system to help the smokers quit their smoking habits. The comprehensive healthcare needs […]
Smoking Among the Youth Population Between 12-25 Years I will use the theory to strengthen the group’s beliefs and ideas about smoking. I will inform the group about the relationship between smoking and human health.
Risks of Smoking Cigarettes Among Preteens Despite the good news that the number of preteen smokers has been significantly reducing since the 1990s, there is still much to be done as the effects of smoking are increasingly building an unhealthy population […]
Healthy People Program: Smoking Issue in Wisconsin That is why to respond to the program’s effective realization, it is important to discuss the particular features of the target population in the definite community of Wisconsin; to focus on the community-based response to […]
Health Campaign: Smoking in the USA and How to Reduce It That is why, the government is oriented to complete such objectives associated with the tobacco use within the nation as the reduction of tobacco use by adults and adolescents, reduction of initiation of tobacco use […]
Smoking Differentials Across Social Classes The author inferred her affirmations from the participant’s words and therefore came to the right conclusion; that low income workers had the least justification for smoking and therefore took on a passive approach to their […]
Cigarette Smoking Side Effects Nicotine is a highly venomous and addictive substance absorbed through the mucous membrane in the mouth as well as alveoli in the lungs.
Long-Term Effects of Smoking The difference between passive smoking and active smoking lies in the fact that, the former involves the exposure of people to environmental tobacco smoke while the latter involves people who smoke directly.
Smoking Cessation Program Evaluation in Dubai The most important program of this campaign is the Quit and Win campaign, which is a unique idea, launched by the DHCC and is in the form of an open contest.
Preterm Birth and Maternal Smoking in Pregnancy The major finding of the discussed research is that both preterm birth and maternal smoking during pregnancy contribute, although independently, to the aortic narrowing of adolescents.
Enforcement of Michigan’s Non-Smoking Law This paper is aimed at identifying a plan and strategy for the enforcement of the Michigan non-smoking law that has recently been signed by the governor of this state.
Smoking Cessation for Patients With Cardio Disorders It highlights the key role of nurses in the success of such programs and the importance of their awareness and initiative in determining prognosis.
Legalizing Electronic Vaping as the Means of Curbing the Rates of Smoking However, due to significantly less harmful effects that vaping produces on health and physical development, I can be considered a legitimate solution to reducing the levels of smoking, which is why it needs to be […]
Drinking, Smoking, and Violence in Queer Community Consequently, the inequality and discrimination against LGBTQ + students in high school harm their mental, emotional, and physical health due to the high level of stress and abuse of various substances that it causes.
Self-Efficacy and Smoking Urges in Homeless Individuals Pinsker et al.point out that the levels of self-efficacy and the severity of smoking urges change significantly during the smoking cessation treatment.
“Cigarette Smoking: An Overview” by Ellen Bailey and Nancy Sprague The authors of the article mentioned above have presented a fair argument about the effects of cigarette smoking and debate on banning the production and use of tobacco in America.
“The Smoking Plant” Project: Artist Statement It is the case when the art is used to pass the important message to the observer. The live cigarette may symbolize the smokers while the plant is used to denote those who do not […]
Dangers of Smoking While Pregnant In this respect, T-test results show that mean birthweight of baby of the non-smoking mother is 3647 grams, while the birthweight of smoking mother is 3373 grams. Results show that gestation value and smoking habit […]
The Cultural Differences of the Tobacco Smoking The Middle East culture is connected to the hookah, the Native American cultures use pipes, and the Canadian culture is linked to cigarettes.
Ban on Smoking in Enclosed Public Places in Scotland The theory of externality explains the benefit or cost incurred by a third party who was not a party to the reasoning behind the benefit or cost. This will also lead to offer of a […]
How Smoking Cigarettes Effects Your Health Cigarette smoking largely aggravates the condition of the heart and the lung. In addition, the presence of nicotine makes the blood to be sticky and thick leading to damage to the lining of the blood […]
Alcohol and Smoking Abuse: Negative Physical and Mental Effects The following is a range of effects of heavy alcohol intake as shown by Lacoste, they include: Neuropsychiatric or neurological impairment, cardiovascular, disease, liver disease, and neoplasm that is malevolent.
Smoking Prohibition: Local Issues, Personal Views This is due to the weakening of blood vessels in the penis. For example, death rate due to smoking is higher in Kentucky than in other parts of the country.
Smoking During Pregnancy Issues Three things to be learned from the research are the impact of smoking on a woman, possible dangers and complications and the importance of smoking cessation interventions.
The Smoking Problem: Mortality, Control, and Prevention The article presents smoking as one of the central problems for many countries throughout the world; the most shocking are the figures related to smoking rate among students. Summary: The article is dedicated to the […]
Tobacco Smoking: Bootleggers and Baptists Legislation or Regulation The issue is based on the fact that tobacco smoking also reduces the quality of life and ruins the body in numerous ways.
Smoking: Causes and Effects Considering the peculiarities of a habit and of a disease, smoking can be considered as a habit rather than a disease.
Smoking Behavior Under Clinical Observation The physiological aspect that influences smokers and is perceived as the immediate effect of smoking can be summarized as follows: Within ten seconds of the first inhalation, nicotine, a potent alkaloid, passes into the bloodstream, […]
Smoking and Its Effect on the Brain Since the output of the brain is behavior and thoughts, dysfunction of the brain may result in highly complex behavioral symptoms. The work of neurons is to transmit information and coordinate messengers in the brain […]
Smoking Causes and Plausible Arguments In writing on the cause and effect of smoking we will examine the issue from the point of view of temporal precedence, covariation of the cause and effect and the explanations in regard to no […]
Post Smoking Cessation Weight Gain The aim of this paper is to present, in brief, the correlation between smoking cessation and weigh gain from biological and psychological viewpoints.
Marketing a Smoking Cessation Program In the case of the smoking cessation program, the target group is made up of smokers who can be further subdivided into segments such as heavy, medium, and light smokers.
Smoking Cessation for Ages 15-30 The Encyclopedia of Surgery defines the term “Smoking Cessation” as an effort to “quit smoking” or “withdrawal from smoking”. I aim to discuss the importance of the issue by highlighting the most recent statistics as […]
Motivational Interviewing as a Smoking Cessation Intervention for Patients With Cancer The dependent variable is the cessation of smoking in 3 months of the interventions. The study is based on the author’s belief that cessation of smoking influences cancer-treated patients by improving the efficacy of treatment.
Factors Affecting the Success in Quitting Smoking of Smokers in West Perth, WA Australia Causing a wide array of diseases, health smoking is the second cause of death in the world. In Australia, the problem of smoking is extremely burning due to the high rates of diseases and deaths […]
Media Effects on Teen Smoking But that is not how an adult human brain works, let alone the young and impressionable minds of teenagers, usually the ads targeted at the youth always play upon elements that are familiar and appealing […]
“Passive Smoking Greater Health Hazard: Nimhans” by Stephen David The article focuses on analyzing the findings of the study and compares them to the reactions to the ban on public smoking.
Partnership in Working About Smoking and Tobacco Use The study related to smoking and tobacco use, which is one of the problematic areas in terms of the health of the population.
Cigar Smoking and Relation to Disease The article “Effect of cigar smoking on the risk of cardiovascular disease, chronic obstructive pulmonary disease and cancer in Men” by Iribarren et al.is a longitudinal study of cigar smokers and the impact of cigar […]
Quitting Smoking: Motivation and Brain As these are some of the observed motivations for smoking, quitting smoking is actually very easy in the sense that you just have to set your mind on quitting smoking.
Health Effects of Tobacco Smoking in Hispanic Men The Health Effects of Tobacco Smoking can be attributed to active tobacco smoking rather than inhalation of tobacco smoke from environment and passive smoking.
Smoking in Adolescents: A New Threat to the Society Of the newer concerns about the risks of smoking and the increase in its prevalence, the most disturbing is the increase in the incidences of smoking among the adolescents around the world.
The Importance of Nurses in Smoking-Cessation Programs When a patient is admitted to the hospital, the nursing staff has the best opportunity to assist them in quitting in part because of the inability to smoke in the hospital combined with the educational […]
New Jersey Legislation on Smoking The advantages and disadvantages of the legislation were discussed in this case because of the complexity of the topic at hand as well as the potential effects of the solution on the sphere of public […]
Environmental Health: Tabaco Smoking and an Increased Concentration of Carbon Monoxide The small size of the town, which is around 225000 people, is one of the reasons for high statistics in diseases of heart rate.
Advanced Pharmacology: Birth Control for Smokers The rationale for IUD is the possibility to control birth without the partner’s participation and the necessity to visit a doctor just once for the device to be implanted.
Legislation Reform of Public Smoking Therefore, the benefit of the bill is that the health hazard will be decreased using banning smoking in public parks and beaches.
Female Smokers Study: Inferential Statistics Article The article “Differential Effects of a Body Image Exposure Session on Smoking Urge between Physically Active and Sedentary Female Smokers” deepens the behavioral mechanisms that correlate urge to smoke, body image, and physical activity among […]
Smoking Bans: Protecting the Public and the Children of Smokers The purpose of the article is to show why smoking bans aim at protecting the public and the children of smokers.
Clinical Effects of Cigarette Smoking Smoking is a practice that should be avoided or controlled rigorously since it is a risk factor for diseases such as cancer, affects the health outcomes of direct and passive cigarette users, children, and pregnant […]
Public Health and Smoking Prevention Smoking among adults over 18 years old is a public health issue that requires intervention due to statistical evidence of its effects over the past decades.
Smoking in the US: Statistics and Healthcare Costs According to the Centers for Disease Control and Prevention, tobacco smoking is the greatest preventable cause of death in the US.
Smoking Should Be Banned Internationally The questions refer to the knowledge concerning the consequences of smoking and the opinions on smoking bans. 80 % of respondents agree that smoking is among the leading causes of death and 63, 3 % […]
Microeconomics: Cigarette Taxes and Public Smoking Ban The problem of passive smoking will be minimized when the number of smokers decreases. It is agreeable that the meager incomes of such families will be used to purchase cigarettes.
Alcohol and Smoking Impact on Cancer Risk The research question is to determine the quantity of the impact that different levels of alcohol ingestion combined with smoking behavioral patterns make on men and women in terms of the risks of cancer.
Teenagers Motivated to Smoking While the rest of the factors also matter much in the process of shaping the habit of smoking, it is the necessity to mimic the company members, the leader, or any other authority that defines […]
Indoor Smoking Restriction Effects at the Workplace Regrettably, they have neglected research on the effect of the legislation on the employees and employers. In this research, the target population will be the employees and employers of various companies.
Hypnotherapy Session for Smoking Cessation When I reached the age of sixty, I realized that I no longer wanted to be a smoker who was unable to take control of one’s lifestyle.
Stopping Tobacco Smoking: Lifestyle Management Plan In addition, to set objective goals, I have learned that undertaking my plan with reference to the modifying behaviour is essential for the achievement of the intended goals. The main intention of the plan is […]
Smoking Epidemiology Among High School Students In this way, with the help of a cross-sectional study, professionals can minimalize the risk of students being afraid to reveal the fact that they smoke. In this way, the number of students who smoke […]
Social Marketing: The Truth Anti-Smoking Campaign The agreement of November 1998 between 46 states, five territories of the United States, the District of Columbia, and representatives of the tobacco industry gave start to the introduction of the Truth campaign.
Vancouver Coastal Health Smoking Cessation Program The present paper provides an evaluation of the Vancouver Coastal Health smoking cessation program from the viewpoint of the social cognitive theory and the theory of planned behavior.
Smoking Experience and Hidden Dangers When my best college friend Jane started smoking, my eyes opened on the complex nature of the problem and on the multiple negative effects of smoking both on the smoker and on the surrounding society.
South Illinois University’s Smoking Ban Benefits The purpose of this letter is to assess the possible benefits of the plan and provide an analysis of the costs and consequences of the smoking ban introduction.
Smoking Cessation in Patients With COPD The strategy of assessing these papers to determine their usefulness in EBP should include these characteristics, the overall quality of the findings, and their applicability in a particular situation. The following article is a study […]
Smoking Bans: Preventive Measures There have been several public smoking bans that have proved to be promising since the issue of smoking prohibits smoking in all public places. This means it is a way of reducing the exposure to […]
Ban Smoking Near the Child: Issues of Morality The decision to ban smoking near the child on father’s request is one of the demonstrative examples. The father’s appeal to the Supreme Court of California with the requirement to prohibit his ex-wife from smoking […]
The Smoking Ban: Arguments Comparison The first argument against banning smoking employs the idea that smoking in specially designated areas cannot do harm to the health of non-smokers as the latter are supposed to avoid these areas.
Smoking Cessation and Patient Education in Nursing Pack-years are the concept that is used to determine the health risks of a smoking patient. The most important step in the management plan is to determine a date when the man should quit smoking.
Philip Morris Company’s Smoking Prevention Activity Philip Morris admits the existence of scientific proof that smoking leads to lung cancer in addition to other severe illnesses even after years of disputing such findings from health professionals.
Tobacco Smoking and Its Dangers Sufficient evidence also indicates that smoking is correlated with alcohol use and that it is capable of affecting one’s mental state to the point of heightening the risks of development of disorders.
Virginia Slims’ Impact on Female Smokers’ Number Considering this, through the investigation of Philip Morris’ mission which it pursued during the launch of the Virginia Slims campaign in 1968-1970 and the main regulatory actions undertaken by the Congress during this period, the […]
Cigarette Smoking and Parkinson’s Disease Risk Therefore, given the knowledge that cigarette smoking protects against the disease, it is necessary to determine the validity of these observations by finding the precise relationship between nicotine and PD.
Tuberculosis Statistics Among Cigarette Smokers The proposal outlines the statistical applications of one-way ANOVA, the study participants, the variables, study methods, expected results and biases, and the practical significance of the expected results.
Smoking Ban and UK’s Beer Industry However, there is an intricate type of relationship between the UK beer sector, the smoking ban, and the authorities that one can only understand by going through the study in detail The history of smoking […]
Status of Smoking around the World Economic factors and level of education have contributed a lot to the shift of balance in the status of smoking in the world.
Redwood Associates Company’s Smoking Ethical Issues Although employees are expected to know what morally they are supposed to undertake at their work place, it is the responsibility of the management and generally the Redwood’s hiring authority to give direction to its […]
Smokers’ Campaign: Finding a Home for Ciggy Butts When carrying out the campaign, it is important to know what the situation on the ground is to be able to address the root cause of the problem facing the population.
Mobile Applications to Quit Smoking A critical insight that can be gleaned from the said report is that one of the major factors linked to failure is the fact that smokers were unable to quit the habit on their own […]
Behavior Modification Technique: Smoking Cessation Some of its advantages include: its mode of application is in a way similar to the act of smoking and it has very few side effects.
Quitting Smoking: Strategies and Consequences Thus, for the world to realize a common positive improvement in population health, people must know the consequences of smoking not only for the smoker but also the society. The first step towards quitting smoking […]
Effects of Thought Suppression on Smoking Behavior In the article under analysis called I suppress, Therefore I smoke: Effects of Thought Suppression on Smoking Behavior, the authors dedicate their study to the evaluation of human behavior as well as the influence of […]
Suppressing Smoking Behavior and Its Effects The researchers observed that during the first and the second weeks of the suppressed behavior, the participants successfully managed to reduce their intake of cigarettes.
Smoking Cessation Methods These methods are a part of NRT or nicotine replacement therapy, they work according to the principle of providing the smoker with small portions of nicotine to minimize the addiction gradually and at the same […]
Understanding Advertising: Second-Hand Smoking
People Should Quit Smoking
Importance of Quitting Smoking
Cigarette Smoking in Public Places
Ban of Tobacco Smoking in Jamaica
Anti-Smoking Campaign in Canada
Electronic Cigarettes: Could They Help University Students Give Smoking Up?
Psychosocial Smoking Rehabilitation
The Program on Smoking Cessation for Employees
Tips From Former Smokers (Campaign)
Combating Smoking: Taxation Policies vs. Education Policies
The Program to Quit Smoking
Smoking Culture in Society
Possible Smoking Policies in Florida
Smoking Ban in the State of Florida
Core Functions of Public Health in the Context of Smoking and Heart Disease
Smoking: Pathophysiological Effects
Putting Out the Fires: Will Higher Taxes Reduce the Onset of Youth Smoking?
Smoking Bans in US
Smoking as Activity Enhancer: Schizophrenia and Gender
Health Care Costs for Smokers
Medical Coverage for Smoking Related Diseases
Exposure to mass media proliferate smoking
The Realm of reality: Smoking
Ethical Problem of Smoking
The Rate of Smoking Among HIV Positive Cases.
Studying the Government’s Anti-Smoking Measures
Smoking Should Be Banned In the United States
Effectiveness of Cognitive Behavioral Theory on Smoking Cessation
Effectiveness of the Cognitive Behavioral Therapy for Smoking Cessation
Wayco Company’s Non-smoking Policy
Adverse Aspects of Smoking
Negative Impacts of Smoking on Individuals and Society
Dealing With the Increase in the Number of Smokers Between Ages 17 and 45
Cannabis Smoking in Canada
Smoking Ban in the United States of America
Dangers of Smoking Campaign
Should Cigarettes Be Banned? Essay
Smoking Ban in New York
Smoking and Adolescents
Trends in Smoking Prevalence by Race/Ethnicity
Business Ethics: Smoking Issue
Should Smoking Tobacco Be Classified As an Illegal Drug?
Where Does the Path to Smoking Addiction Start?
Public Health Communication: Quit Smoking
Are Estimated Peer Effects on Smoking Robust?
Are There Safe Smoking and Tobacco Options?
What Are the Health Risks of Smoking?
Does Cigarette Smoking Affect Body Weight?
Does Cigarette Smuggling Prop Up Smoking Rates?
What Foods Help You Quit Smoking?
How Can People Relax Without Smoking?
Does Education Affect Smoking Behaviors?
Is Vaping Worse Than Smoking?
Do Movies Affect Teen Smoking?
What Is Worse: Drinking or Smoking?
Does Smoking Affect Breathing Capacity?
Does Smoking Cause Lung Cancer?
Does Having More Children Increase the Likelihood of Parental Smoking?
Does Smoking Cigarettes Relieve Stress?
Does Time Preference Affect Smoking Behavior?
How Does Smoking Affect Cardiovascular Endurance?
How Hypnosis Can Help You Quit Smoking?
How Does Smoking Affect Brain?
How Nicotine Affects Your Quit Smoking Victory?
How Does Secondhand Smoking Affect Us?
Why Is Smoking Addictive?
How Smoking Bans Are Bad for Business?
Why Smoking Should Not Be Permitted in Restaurants?
Why Public Smoking Should Be Banned?
Why Has Cigarette Smoking Become So Prominent Within the American Culture?
What Makes Smoking and Computers Similar?
Does Smoking Affect Schooling?
What Effects Can Cigarette Smoking Have on the Respiratory System?
What Are the Most Prevalent Dangers of Smoking and Drinking?
Chicago (A-D)
Chicago (N-B)

IvyPanda. (2024, February 29). 235 Smoking Essay Topics & Examples. https://ivypanda.com/essays/topic/smoking-essay-examples/

"235 Smoking Essay Topics & Examples." IvyPanda , 29 Feb. 2024, ivypanda.com/essays/topic/smoking-essay-examples/.

IvyPanda . (2024) '235 Smoking Essay Topics & Examples'. 29 February.

IvyPanda . 2024. "235 Smoking Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/smoking-essay-examples/.

1. IvyPanda . "235 Smoking Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/smoking-essay-examples/.

Bibliography

IvyPanda . "235 Smoking Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/smoking-essay-examples/.

Social Security Paper Topics
Drugs Titles
Cannabis Essay Titles
Global Issues Essay Topics
Cardiovascular Diseases Titles
Marijuana Ideas
NHS Research Ideas
Hypertension Topics

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings
Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

United States Public Health Service Office of the Surgeon General; National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Smoking Cessation: A Report of the Surgeon General [Internet]. Washington (DC): US Department of Health and Human Services; 2020.

Smoking Cessation: A Report of the Surgeon General [Internet].

Chapter 1 introduction, conclusions, and the evolving landscape of smoking cessation.

Introduction

Tobacco smoking is the leading cause of preventable disease, disability, and death in the United States ( U.S. Department of Health and Human Services [USDHHS] 2014 ). Smoking harms nearly every organ in the body and costs the United States billions of dollars in direct medical costs each year ( USDHHS 2014 ). Although considerable progress has been made in reducing cigarette smoking since the first U.S. Surgeon General’s report was released in 1964 ( USDHHS 2014 ), in 2018, 13.7% of U.S. adults (34.2 million people) were still current cigarette smokers ( Creamer et al. 2019 ). One of the main reasons smokers keep smoking is nicotine ( USDHHS 1988 ). Nicotine, a drug found naturally in the tobacco plant, is highly addictive, as with such drugs as cocaine and heroin; activates the brain’s reward circuits; and reinforces repeated nicotine exposure ( USDHHS 1988 , 2010 , 2014 ; National Institute on Drug Abuse [NIDA] 2018 ).

The majority of cigarette smokers (68%) want to quit smoking completely ( Babb et al. 2017 ). The 1990 Surgeon General’s report, The Health Benefits of Smoking Cessation, was the last Surgeon General’s report to focus on current research on smoking cessation and to predominantly review the health benefits of quitting smoking ( USDHHS 1990 ). Because of limited data at that time, the 1990 report did not review the determinants, processes, or outcomes of attempts at smoking cessation. Pharmacotherapy for smoking cessation was not introduced until the 1980s. Additionally, behavioral and other counseling approaches were slow to develop and not widely available at the time of the 1990 report because few were covered under health insurance, and programs such as group counseling sessions were hard for smokers to access, even by those who were motivated to quit ( Fiore et al. 1990 ).

The purpose of this report is to update and expand the 1990 Surgeon General’s report based on new scientific evidence about smoking cessation. Since 1990, the scientific literature has expanded greatly on the determinants and processes of smoking cessation, informing the development of interventions that promote cessation and help smokers quit ( Fiore et al. 2008 ; Schlam and Baker 2013 ). This knowledge and other major developments have transformed the landscape of smoking cessation in the United States. This report summarizes this enhanced knowledge and specifically reviews patterns and trends of smoking cessation; biologic mechanisms; various health benefits; overall morbidity, mortality, and economic benefits; interventions; and strategies that promote smoking cessation.

From 1965 to 2017, the prevalence of current smoking declined from 52.0% to 15.8% (relative percent change: 69.6%) among men and from 34.1% to 12.2% (relative percent change: 64.2%) among women ( Figure 1.1 ). These declines have been attributed, in part, to progress made in smoking cessation since the 1960s, which has continued since the 1990 Surgeon General’s report. Specifically, clinical, scientific, and public health communities have increasingly embraced and acted upon the concept of tobacco use and dependence as a health condition that can benefit from treatment in various forms and levels of intensity. Accordingly, a considerable range of effective pharmacologic and behavioral smoking cessation treatment options are now available. As of October 16, 2019, the U.S. Food and Drug Administration ( FDA ) has approved five nicotine replacement therapies (NRTs) and two non-nicotine oral medications to help smokers quit, and the use of these treatments has expanded, including stronger integration with counseling support ( Fiore et al. 2008 ).

Trends in prevalence (%) of current and former cigarette smoking among adults 18 years of age and older, by sex; National Health Interview Survey (NHIS) 1965–2017; United States. Source: NHIS, National Center for Health Statistics, public use (more...)

In addition, the reach of smoking cessation interventions has increased substantially since 1990 with the emergence of innovative, population-level interventions and policies that motivate smokers to quit and raise awareness of the health benefits of smoking cessation ( McAfee et al. 2013 ). This includes policies, such as comprehensive smokefree laws, that have been shown to promote cessation at the population level in addition to reducing exposure to secondhand smoke ( USDHHS 2014 ). The development and subsequent expansion of telephone call centers (“quitlines”), mobile phone technologies, Internet-based applications, and other innovations have created novel platforms to provide behavioral and pharmacologic smoking cessation treatments ( Ghorai et al. 2014 ). However, the continued diversification of the tobacco product landscape could have several different potential impacts, ranging from accelerating the rates of complete cessation among adult smokers to erasing progress in reducing all forms of use of tobacco products, especially among youth and young adults. For example, the increasing availability and rapidly increasing use of novel tobacco products, most notably electronic cigarettes ( e-cigarettes ), raise questions about the potential impact that such products could have on efforts to eliminate disease and death caused by tobacco use at the individual and population levels. Therefore, when considering the impact of e-cigarettes on public health, it is critical to evaluate their effects on both adults and youth.

Collectively, the changes cited in this report provide new opportunities and challenges for understanding and promoting smoking cessation in the United States. However, the evidence-based clinical-, health system-, and population-based tobacco prevention, control, and cessation strategies that are outlined in this report are a necessary but insufficient means to end the tobacco epidemic. Reaching the finish line will require coordination across federal government agencies and other government and non-government stakeholders at the national, state, and local levels. To achieve success, we must work together to maximize resources and coordinate efforts across a wide range of stakeholders.

Organization of the Report

This chapter summarizes the report, identifies its major conclusions, and presents the conclusions from each chapter. It also offers an overview of the evolving landscape of smoking cessation and key developments since the 1990 Surgeon General’s report. Chapter 2 (“Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth”) documents key patterns and trends in cigarette smoking cessation in the United States among adults overall (persons 18 years of age and older), young adults (18–24 years of age), and youth (12–17 years of age). The chapter also reviews the changing demographic- and smoking-related characteristics of cigarette smokers with a focus on how these changes may influence future trends in cessation. Chapter 3 (“New Biological Insights into Smoking Cessation”) reviews several areas of intensive research since the 2010 Surgeon General’s report on how tobacco smoke causes disease: cellular and molecular biology of nicotine addiction; vaccines and other immunotherapies as treatments for tobacco addiction; neurobiological insights into smoking cessation obtained from noninvasive neuroimaging; and genetics of smoking behaviors and cessation. Chapter 4 (“The Health Benefits of Smoking Cessation”) reviews the more recent findings on disease risks from smoking and benefits after smoking cessation for major types of chronic diseases, including cardiovascular and respiratory systems, cancer, and a wide range of reproductive outcomes. Chapter 5 (“The Benefits of Smoking Cessation on Overall Morbidity, Mortality, and Economic Costs”) discusses general indicators of health that change after smoking cessation, the health benefits of smoking cessation on all-cause mortality, and the economic benefits of smoking cessation. Chapter 6 (“Interventions for Smoking Cessation and Treatments for Nicotine Dependence”) reviews the evidence on current and emerging treatments for smoking cessation, including research that has been conducted since the 2008 U.S. Public Health Service’s Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update ( Fiore et al. 2008 ). Chapter 7 (“Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation”) focuses on clinical-, system-, and population-level strategies that combine individual components of treatment for smoking cessation with routine clinical care, making cessation interventions available and accessible to individual smokers and creating conditions whereby smokers are informed of these interventions and are motivated to use them. Chapter 8 (“A Vision for the Future”) outlines broad strategies to accelerate the progress that has been made in helping smokers quit.

Preparation of the Report

This Surgeon General’s report was prepared by the Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention ( CDC ), which is part of USDHHS . This report was compiled using a longstanding, peer-reviewed, balanced, and comprehensive process designed to safeguard the scientific rigor and practical relevance from influences that could adversely affect impartiality ( King et al. 2018 ). This process helps to ensure that the report’s conclusions are defined by the evidence, rather than the opinions of the authors and editors. In brief, under the leadership of a senior scientific editorial team, 32 experts wrote the initial drafts of the chapters. The experts were selected for their knowledge of the topics addressed. These contributions, which are summarized in Chapters 1 – 7 , were evaluated by 46 peer reviewers. After this initial stage of peer review, more than 20 senior scientists and other experts examined the scientific integrity of the entire manuscript as part of a second stage of peer review. After each round of peer review, the report’s scientific editors revised each draft based on reviewers’ comments. Chapter 8 , which summarizes and is founded upon the preceding content in the report, was written by the senior scientific editorial team once the content in Chapters 1 – 7 completed peer review. Subsequently, the report was reviewed by various institutes and agencies in the U.S. government, including USDHHS. Throughout the review process, the content of each chapter was revised to include studies and information that were not available when the chapters were first drafted; updates were made until shortly before the report was submitted for publication. These updates reflect the full scope of identified evidence, including new findings that confirm, refute, or refine the initial content. Conclusions are based on the preponderance and quality of scientific evidence.

Scientific Basis of the Report

The statements and conclusions throughout this report are based on an extensive review of the existing scientific literature. Thus, the report focuses primarily on cessation in the context of adults because this is the population for which the preponderance of scientific literature exists on this topic; however, data on youth and young adults are also presented, when available. The report primarily cites peer-reviewed journal articles, including reviews that integrate findings from numerous studies and books that were published between 2000 and 2018, which reflects a period after the last Surgeon General’s report on the topic of cessation. This report also refers, on occasion, to unpublished research, such as presentations at professional meetings, personal communications from researchers, and information available in various media. These references are used when acknowledged by the editors and reviewers as being scientifically valid and reliable, and a critical addition to the emerging literature on a topic. Throughout the writing and review process, highest priority was given to peer-reviewed, scientific research that is free from tobacco industry interests. As noted in the 2014 Surgeon General’s report, the tobacco industry has a well-documented record of manipulating scientific information about the extent of the harms from cigarette smoking ( USDHHS 2014 ).

Consistency of the association,
Strength of the association,
Specificity of the association,
Temporal relationship of the association, and
Coherence of the association ( U.S. Department of Health, Education, and Welfare [USDHEW] 1964 , p. 20).
“Evidence is sufficient to infer a causal relationship.
Evidence is suggestive but not sufficient to infer a causal relationship.
Evidence is inadequate to infer the presence or absence of a causal relationship (which encompasses evidence that is sparse, of poor quality, or conflicting).
Evidence is suggestive of no causal relationship ” ( USDHHS 2004 , p. 18).
Do multiple high-quality studies show a consistent association between smoking and disease?
Are the measured effects large enough and statistically strong?
Does the evidence show that smoking occurs before the disease occurs (a temporal association)?
Is the relationship between smoking and disease coherent or plausible in terms of known scientific principles, biologic mechanisms, and observed patterns of disease?
Is there a dose-response relationship between smoking and disease?
Is the risk of disease reduced after quitting smoking?

The categories acknowledge that evidence can be “suggestive but not sufficient” to infer a causal relationship, and the categories allow for evidence that is “suggestive of no causal relationship.” This framework also separates conclusions about causality from the implications of such conclusions. Inference is sharply and completely separated from policy or research implications of the conclusions, thus adhering to the approach established in the 1964 report. However, consistent with past Surgeon General’s reports on tobacco, conclusions are not limited to just causal determinations and frequently include recommendations for research, policies, or other actions.

Major Conclusions
Smoking cessation is beneficial at any age. Smoking cessation improves health status and enhances quality of life.
Smoking cessation reduces the risk of premature death and can add as much as a decade to life expectancy.
Smoking places a substantial financial burden on smokers, healthcare systems, and society. Smoking cessation reduces this burden, including smokingattributable healthcare expenditures.
Smoking cessation reduces risk for many adverse health effects, including reproductive health outcomes, cardiovascular diseases, chronic obstructive pulmonary disease, and cancer. Quitting smoking is also beneficial to those who have been diagnosed with heart disease and chronic obstructive pulmonary disease.
More than three out of five U.S. adults who have ever smoked cigarettes have quit. Although a majority of cigarette smokers make a quit attempt each year, less than one-third use cessation medications approved by the U.S. Food and Drug Administration or behavioral counseling to support quit attempts.
Considerable disparities exist in the prevalence of smoking across the U.S. population, with higher prevalence in some subgroups. Similarly, the prevalence of key indicators of smoking cessation—quit attempts, receiving advice to quit from a health professional, and using cessation therapies—also varies across the population, with lower prevalence in some subgroups.
Smoking cessation medications approved by the U.S. Food and Drug Administration and behavioral counseling are cost-effective cessation strategies. Cessation medications approved by the U.S. Food and Drug Administration and behavioral counseling increase the likelihood of successfully quitting smoking, particularly when used in combination. Using combinations of nicotine replacement therapies can further increase the likelihood of quitting.
Insurance coverage for smoking cessation treatment that is comprehensive, barrier-free, and widely promoted increases the use of these treatment services, leads to higher rates of successful quitting, and is cost-effective.
E-cigarettes, a continually changing and heterogeneous group of products, are used in a variety of ways. Consequently, it is difficult to make generalizations about efficacy for cessation based on clinical trials involving a particular e-cigarette, and there is presently inadequate evidence to conclude that e-cigarettes , in general, increase smoking cessation.
Smoking cessation can be increased by raising the price of cigarettes, adopting comprehensive smokefree policies, implementing mass media campaigns, requiring pictorial health warnings, and maintaining comprehensive statewide tobacco control programs.
Chapter Conclusions

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

In the United States, more than three out of every five adults who were ever cigarette smokers have quit smoking.
Past-year quit attempts and recent and longer term cessation have increased over the past 2 decades among adult cigarette smokers.
Marked disparities in cessation behaviors, such as making a past-year quit attempt and achieving recent successful cessation, persist across certain population subgroups defined by educational attainment, poverty status, age, health insurance status, race/ethnicity, and geography.
Advice from health professionals to quit smoking has increased since 2000; however, four out of every nine adult cigarette smokers who saw a health professional during the past year did not receive advice to quit.
Use of evidence-based cessation counseling and/or medications has increased among adult cigarette smokers since 2000; however, more than two-thirds of adult cigarette smokers who tried to quit during the past year did not use evidence-based treatment.
A large proportion of adult smokers report using non-evidence-based approaches when trying to quit smoking, such as switching to other tobacco products.

Chapter 3. New Biological Insights into Smoking Cessation

The evidence is suggestive but not sufficient to infer that increasing glutamate transport can alleviate nicotine withdrawal symptoms and prevent relapse.
The evidence is suggestive but not sufficient to infer that neuropeptide systems play a role in multiple stages of the nicotine addiction process, and that modulating the function of certain neuropeptides can reduce smoking behavior in humans.
The evidence is suggestive but not sufficient to infer that targeting the habenulo-interpeduncular pathway with agents that increase the aversive properties of nicotine are a useful therapeutic target for smoking cessation.
The evidence is suggestive but not sufficient to infer that vaccines generating adequate levels of nicotinespecific antibodies can block the addictive effects of nicotine and aid smoking cessation.
The evidence is suggestive but not sufficient to infer that dysregulated brain circuits, including prefrontal and cingulate cortical regions and their connections with various striatal and insula loci, can serve as novel therapeutic targets for smoking cessation.
The evidence is suggestive but not sufficient to infer that the effectiveness of nicotine replacement therapy may vary across specific genotype groups.

Chapter 4. The Health Benefits of Smoking Cessation

The evidence is sufficient to infer that smoking cessation reduces the risk of lung cancer.
The evidence is sufficient to infer that smoking cessation reduces the risk of laryngeal cancer.
The evidence is sufficient to infer that smoking cessation reduces the risk of cancers of the oral cavity and pharynx
The evidence is sufficient to infer that smoking cessation reduces the risk of esophageal cancer.
The evidence is sufficient to infer that smoking cessation reduces the risk of pancreatic cancer.
The evidence is sufficient to infer that smoking cessation reduces the risk of bladder cancer.
The evidence is sufficient to infer that smoking cessation reduces the risk of stomach cancer.
The evidence is sufficient to infer that smoking cessation reduces the risk of colorectal cancer.
The evidence is sufficient to infer that smoking cessation reduces the risk of liver cancer.
The evidence is sufficient to infer that smoking cessation reduces the risk of cervical cancer.
The evidence is sufficient to infer that smoking cessation reduces the risk of kidney cancer.
The evidence is sufficient to infer that smoking cessation reduces the risk of acute myeloid leukemia.
The evidence is sufficient to infer that the relative risk of lung cancer decreases steadily after smoking cessation compared with the risk for persons continuing to smoke, with risk decreasing to half that of continuing smokers approximately 10–15 years after smoking cessation and decreasing further with continued cessation.

Smoking Cessation After a Cancer Diagnosis

The evidence is suggestive but not sufficient to infer a causal relationship between smoking cessation and improved all-cause mortality in cancer patients who are current smokers at the time of a cancer diagnosis.

Cardiovascular Disease

The evidence is sufficient to infer that smoking cessation reduces levels of markers of inflammation and hypercoagulability and leads to rapid improvement in the level of high-density lipoprotein cholesterol.
The evidence is sufficient to infer that smoking cessation leads to a reduction in the development of subclinical atherosclerosis, and that progression slows as time since cessation lengthens.
The evidence is sufficient to infer that smoking cessation reduces the risk of cardiovascular morbidity and mortality and the burden of disease from cardiovascular disease.
The evidence is sufficient to infer that the relative risk of coronary heart disease among former smokers compared with never smokers falls rapidly after cessation and then declines more slowly.
The evidence is sufficient to infer that smoking cessation reduces the risk of stroke morbidity and mortality.
The evidence is sufficient to infer that, after smoking cessation, the risk of stroke approaches that of never smokers.
The evidence is suggestive but not sufficient to infer that smoking cessation reduces the risk of atrial fibrillation.
The evidence is suggestive but not sufficient to infer that smoking cessation reduces the risk of sudden cardiac death among persons without coronary heart disease.
The evidence is suggestive but not sufficient to infer that smoking cessation reduces the risk of heart failure among former smokers compared with persons who continue to smoke.
Among patients with left-ventricular dysfunction, the evidence is suggestive but not sufficient to infer that smoking cessation leads to increased survival and reduced risk of hospitalization for heart failure.
The evidence is suggestive but not sufficient to infer that smoking cessation reduces the risk of venous thromboembolism.
The evidence is suggestive but not sufficient to infer that smoking cessation substantially reduces the risk of peripheral arterial disease among former smokers compared with persons who continue to smoke, and that this reduction appears to increase with time since cessation.
The evidence is suggestive but not sufficient to infer that, among patients with peripheral arterial disease, smoking cessation improves exercise tolerance, reduces the risk of amputation after peripheral artery surgery, and increases overall survival.
The evidence is sufficient to infer that smoking cessation substantially reduces the risk of abdominal aortic aneurysm in former smokers compared with persons who continue to smoke, and that this reduction increases with time since cessation.
The evidence is suggestive but not sufficient to infer that smoking cessation slows the expansion rate of abdominal aortic aneurysm.

Smoking Cessation After a Diagnosis of Coronary Heart Disease

In patients who are current smokers when diagnosed with coronary heart disease, the evidence is sufficient to infer a causal relationship between smoking cessation and a reduction in all-cause mortality.
In patients who are current smokers when diagnosed with coronary heart disease, the evidence is sufficient to infer a causal relationship between smoking cessation and reductions in deaths due to cardiac causes and sudden death.
In patients who are current smokers when diagnosed with coronary heart disease, the evidence is sufficient to infer a causal relationship between smoking cessation and reduced risk of new and recurrent cardiac events.

Chronic Respiratory Disease

Chronic obstructive pulmonary disease.

Smoking cessation remains the only established intervention to reduce loss of lung function over time among persons with chronic obstructive pulmonary disease and to reduce the risk of developing chronic obstructive pulmonary disease in cigarette smokers.
The evidence is suggestive but not sufficient to infer that airway inflammation in cigarette smokers persists months to years after smoking cessation.
The evidence is suggestive but not sufficient to infer that changes in gene methylation and profiles of proteins occur after smoking cessation.
The evidence is inadequate to infer the presence or absence of a relationship between smoking cessation and changes in the lung microbiome.
The evidence is suggestive but not sufficient to infer that smoking cessation reduces asthma symptoms and improves treatment outcomes and asthma-specific quality-of-life scores among persons with asthma who smoke.
The evidence is suggestive but not sufficient to infer that smoking cessation improves lung function among persons with asthma who smoke.

Reproductive Health

The evidence is sufficient to infer that smoking cessation by pregnant women benefits their health and that of their fetuses and newborns.
The evidence is inadequate to infer that smoking cessation before or during early pregnancy reduces the risk of placental abruption compared with continued smoking.
The evidence is inadequate to infer that smoking cessation before or during pregnancy reduces the risk of placenta previa compared with continued smoking.
The evidence is inadequate to infer that smoking cessation before or during pregnancy reduces the risk of premature rupture of the membranes compared with continued smoking.
The evidence is inadequate to infer that smoking during early or mid-pregnancy alone, and not during late pregnancy, is associated with a reduced risk of preeclampsia.
The evidence is sufficient to infer that women who quit smoking before or during pregnancy gain more weight during gestation than those who continue to smoke.
The evidence is suggestive but not sufficient to infer that women who quit smoking before or during pregnancy gain more weight during gestation than nonsmokers.
The evidence is inadequate to infer that smoking cessation during pregnancy increases the risk of gestational diabetes.
The evidence is sufficient to infer that smoking cessation during pregnancy reduces the effects of smoking on fetal growth and that quitting smoking early in pregnancy eliminates the adverse effects of smoking on fetal growth.
The evidence is inadequate to determine the gestational age before which smoking cessation should occur to eliminate the effects of smoking on fetal growth.
The evidence is sufficient to infer that smoking cessation before or during early pregnancy reduces the risk for a small-for-gestational-age birth compared with continued smoking.
The evidence is suggestive but not sufficient to infer that women who quit smoking before conception or during early pregnancy have a reduced risk of preterm delivery compared with women who continue to smoke.
The evidence is suggestive but not sufficient to infer that the risk of preterm delivery in women who quit smoking before or during early pregnancy does not differ from that of nonsmokers.
The evidence is inadequate to infer that smoking cessation during pregnancy reduces the risk of stillbirth.
The evidence is inadequate to infer that smoking cessation during pregnancy reduces the risk of perinatal mortality among smokers.
The evidence is inadequate to infer that women who quit smoking before or during early pregnancy have a reduced risk for infant mortality compared with continued smokers.
The evidence is inadequate to infer an association between smoking cessation, the timing of cessation, and female fertility or fecundity.
The evidence is suggestive but not sufficient to infer that smoking cessation reduces the risk of earlier age at menopause compared with continued smoking.
The evidence is inadequate to infer that smoking cessation reduces the effects of smoking on male fertility and sperm quality.
The evidence is suggestive but not sufficient to infer that former smokers are at increased risk of erectile dysfunction compared with never smokers.
The evidence is inadequate to infer that smoking cessation reduces the risk of erectile dysfunction compared with continued smoking.

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

The evidence is sufficient to infer that smoking cessation improves well-being, including higher quality of life and improved health status.
The evidence is sufficient to infer that smoking cessation reduces mortality and increases the lifespan.
The evidence is sufficient to infer that smoking exacts a high cost for smokers, healthcare systems, and society.
The evidence is sufficient to infer that smoking cessation interventions are cost-effective.

Chapter 6. Interventions for Smoking Cessation and Treatments for Nicotine Dependence

The evidence is sufficient to infer that behavioral counseling and cessation medication interventions increase smoking cessation compared with self-help materials or no treatment.
The evidence is sufficient to infer that behavioral counseling and cessation medications are independently effective in increasing smoking cessation, and even more effective when used in combination.
The evidence is sufficient to infer that proactive quitline counseling, when provided alone or in combination with cessation medications, increases smoking cessation.
The evidence is sufficient to infer that short text message services about cessation are independently effective in increasing smoking cessation, particularly if they are interactive or tailored to individual text responses.
The evidence is sufficient to infer that web or Internetbased interventions increase smoking cessation and can be more effective when they contain behavior change techniques and interactive components.
The evidence is inadequate to infer that smartphone apps for smoking cessation are independently effective in increasing smoking cessation.
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.
The evidence is suggestive but not sufficient to infer that pre-loading (e. g ., initiating cessation medication in advance of a quit attempt), especially with the nicotine patch, can increase smoking cessation.
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.
The evidence is inadequate to infer that e-cigarettes , in general, increase smoking cessation. However, the evidence is suggestive but not sufficient to infer that the use of e-cigarettes containing nicotine is associated with increased smoking cessation compared with the use of e-cigarettes not containing nicotine, and the evidence is suggestive but not sufficient to infer that more frequent use of e-cigarettes is associated with increased smoking cessation compared with less frequent use of e-cigarettes.
The evidence is sufficient to infer that certain life events—including hospitalization, surgery, and lung cancer screening—can trigger attempts to quit smoking, uptake of smoking cessation treatment, and smoking cessation.
The evidence is suggestive but not sufficient to infer that fully and consistently integrating standardized, evidence-based smoking cessation interventions into lung cancer screening increases smoking cessation while avoiding potential adverse effects of this screening on cessation outcomes.
The evidence is suggestive but not sufficient to infer that cytisine increases smoking cessation.

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

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.
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.
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.
The evidence is sufficient to infer that tobacco quitlines are an effective population-based approach to motivate quit attempts and increase smoking cessation.
The evidence is suggestive but not sufficient to infer that electronic health record technology increases the rate of delivery of smoking cessation treatments.
The evidence is sufficient to infer that increasing the price of cigarettes reduces smoking prevalence, reduces cigarette consumption, and increases smoking cessation.
The evidence is sufficient to infer that smokefree policies reduce smoking prevalence, reduce cigarette consumption, and increase smoking cessation.
The evidence is sufficient to infer that mass media campaigns increase the number of calls to quitlines and increase smoking cessation.
The evidence is sufficient to infer that comprehensive state tobacco control programs reduce smoking prevalence, increase quit attempts, and increase smoking cessation.
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.
The evidence is suggestive but not sufficient to infer that plain packaging increases smoking cessation.
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.
The evidence is suggestive but not sufficient to infer that restricting the sale of certain types of tobacco products, such as menthol and other flavored products, increases smoking cessation, especially among certain populations.
The Evolving Landscape of Smoking Cessation

This section of the chapter reviews the history of smoking cessation, from its early origins to the modern era, including the changes that have occurred since publication of the 1990 Surgeon General’s report. It also highlights developments that have shaped current initiatives in smoking cessation and will set the stage for the chapters that follow. Finally, this section highlights a broad set of interventions that have been implemented over the past three decades and are proven to be effective at helping people quit successfully. These interventions, which are now being integrated into clinical care and societal policies, include (a) low-intensity interventions, such as telephone quitlines; (b) brief but systematically repeated interventions in primary care settings; (c) over-the-counter medications; and (d) public policy approaches, such as increases in tobacco prices (e. g ., through taxation), comprehensive policies to make indoor environments smokefree, and mass media campaigns that increase motivation to quit and may help sustain quit attempts ( CDC 2014a ; USDHHS 2014 ).

Historical Context of Smoking Cessation

Addiction versus habit.

“Smoking is highly addictive. Nicotine is the addictive drug in tobacco”;
“Cigarette companies intentionally designed cigarettes with enough nicotine to create and sustain addiction”;
“It’s not easy to quit”; and
“When you smoke, the nicotine actually changes the brain—that’s why quitting is so hard” ( U.S. Department of Justice 2017a ; Farber et al. 2018 , p. 128).

However, previously secret documents from the tobacco industry reveal that the tobacco industry was aware of the addictive nature of nicotine for decades, long before they publicly acknowledged it or were eventually ordered by the court to publicly acknowledge it ( Elias et al. 2018 ). In fact, the tobacco industry had been engineering cigarettes for decades to improve the rapid delivery of nicotine ( Proctor 2011 ). For years, the tobacco industry coordinated well-financed, systematic efforts to deny the addictiveness of nicotine and the need for users to quit smoking, thereby trivializing the harms of tobacco use while promoting the benefits of nicotine ( Hirschhorn 2009 ; USDHHS 2014 ). The industry did this using welldocumented tactics, including aggressive funding and support for academic, medical, and community organizations that were sympathetic to this perspective ( Proctor 2011 ).

Addiction to any substance often brings on a variety of efforts to overcome or treat it. However, until the late twentieth century, clinical and public health approaches to smoking cessation often treated smoking as a habit rather than as an addiction ( USDHEW 1964 ). The tobacco industry has asserted for many years in public messaging and litigation that smoking is a personal choice ( Friedman et al. 2015 ). Indeed, both smoking and smoking cessation were considered personal choices; the idea was that if persons started smoking cigarettes, they could quit if they truly wanted to, putting the onus on the individual smoker to quit using his or her own motivation and desire to do so. The Surgeon General first concluded in 1988 that “cigarettes and other forms of tobacco are addicting,” and “nicotine is the drug in tobacco that causes addiction” ( USDHHS 1988 , p. 9). Eventually, intensive medical treatments and protocols—such as the use of multiple medications for long periods of time, long-term psychological counseling, and inpatient hospitalization—were developed to address the highly addictive nature of nicotine ( Fiore et al. 2008 ). However, between 2000 and 2015, less than one-third of U.S. adult cigarette smokers reported using evidence-based cessation treatments, such as behavioral counseling and/or medication, when trying to quit smoking ( Babb et al. 2017 ).

The first comprehensive clinical practice guideline for smoking cessation was produced by the federal government in 1996 and emphasized the role of healthcare providers in providing assessment and treatment interventions for smoking with patients who smoke ( Fiore et al. 1996 ). In 2008, an updated federal guideline, Treating Tobacco Use and Dependence: 2008 Update (hereafter referred to as the Clinical Practice Guideline ), was published ( Fiore et al. 2008 ). This guideline uses language similar to that used in helping persons quit other addictive substances and is discussed in more detail in Chapter 7 .

With the shift toward an improved understanding of the nature of nicotine addiction, terminology used to describe tobacco use has also shifted. The Diagnostic and Statistical Manual of Mental Disorders (5th edition) is the primary clinical source of diagnostic criteria for mental health disorders. It provides diagnostic criteria for “tobacco use disorder,” which includes physiologic dependence, impaired control, and social impairment, among others ( American Psychiatric Association 2013 ). These diagnostic criteria align with those for other substance use disorders and acknowledge the physical, psychological, and environmental components of addiction. However, as noted in the Clinical Practice Guideline, although not all tobacco use results in tobacco use disorder, any tobacco use has risks and, therefore, warrants intervention ( Fiore et al. 2008 ). Accordingly, throughout this report, the term “tobacco use and dependence” is used to be inclusive of all patterns of use and to acknowledge the multifactorial and chronic relapsing nature of nicotine addiction. The term “nicotine dependence” is used specifically to refer to physiologic dependence on nicotine. This terminology aligns with that used in the Clinical Practice Guideline, which further details why the term “tobacco use and dependence” is most appropriate when discussing cessation interventions ( Fiore et al. 2008 ).

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

Coverage of cessation, nicotine, and addiction in Surgeon General’s reports has evolved greatly since 1964, reflecting the evolution of scientific understanding of addiction to nicotine and its treatment.

Coverage of Smoking Cessation

Of the 34 Surgeon General’s reports on smoking and health published to date, this is the second to address smoking cessation as the main topic. Even so, beginning with the first report in 1964, evidence reviewed in various reports has supported some conclusions related to the health benefits of smoking cessation. Over time, as the epidemiologic findings from prospective cohort studies became more abundant and covered longer periods of time since quitting smoking, conclusions began to mount on the decline in risks for major smoking-caused diseases after cessation. In fact, declines in risk after cessation figured into the causal inference process presented in the reports, which documented a decrease in health risks after withdrawal of smoking—the presumptive causal agent.

The 1964 Surgeon General’s report reviewed findings from seven prospective cohort studies that had included sufficient numbers of former smokers to provide estimates about cause-specific relative risk for mortality from selected diseases ( USDHEW 1964 ). The data from the cohort studies were complemented by case-control studies for some cancer sites that had also addressed a change in risk after smoking cessation. For all-cause mortality, the 1964 report stated that compared with never smokers, relative mortality was 40% higher among former smokers and 70% higher among current smokers. For lung cancer, quantitative relationships with smoking patterns were described as follows: “The risk of developing lung cancer increases with duration of smoking and the number of cigarettes smoked per day, and is diminished by discontinuing smoking” (p. 37). In considering the causal nature of the association between smoking and lung cancer, the report stated, “Where discontinuance, time since discontinuance, and amount smoked prior to discontinuance were considered in either retrospective studies or, with more detail, in prospective studies, these all showed lower risks for ex-smokers, still lower risks as the length of time since discontinuance increased, and lower risks among ex-smokers if they had been light smokers” (p. 188). The report did not conclude that smoking caused cardiovascular disease, but it noted a lower risk of death from cardiovascular disease among former smokers compared with continuing smokers and stated, “Although the causative role of cigarette smoking in deaths from coronary disease is not proven, the Committee considers it more prudent from the public health viewpoint to assume that the established association has causative meaning than to suspend judgment until no uncertainty remains” (p. 32).

In ensuing Surgeon General’s reports through the 1970s, the health benefits of smoking cessation did not receive systematic attention, but the results identified a declining risk for some diseases after cessation. The 1979 report offered detailed reviews for major diseases, and it concluded that compared with smokers, risks were lower among former smokers for all-cause mortality, atherosclerosis and coronary heart disease, lung cancer, larynx cancer, lung function, and respiratory symptoms ( USDHEW 1979 ). Three Surgeon General’s reports released in the early 1980s focused on the health consequences of smoking on specific major disease categories: cancer ( USDHHS 1982 ), cardiovascular disease ( USDHHS 1983 ), and chronic lung disease ( USDHHS 1984 ). Each report also examined the impact of smoking cessation on each of those disease categories. In 1988, the report reviewed the evidence to date on nicotine and drew major conclusions that nicotine was addictive ( USDHHS 1988 ).

By 1990, the scope and depth of evidence on smoking cessation was sufficiently abundant to justify a full report, The Health Benefits of Smoking Cessation . The report’s conclusions expanded on those of earlier reports, summarizing descriptions of the temporal course of declining risk for many of the diseases caused by smoking ( USDHHS 1990 ). For example, the report concluded, “The excess risk of [coronary heart disease] caused by smoking is reduced by about half after 1 year of smoking abstinence and then declines gradually. After 15 years of abstinence, the risk of [coronary heart disease] is similar to that of persons who have never smoked” (p. 11).

Importantly, the 1990 report was the first to address smoking cessation and reproduction. That report offered strong conclusions with clinical implications related to reproduction and offered conclusions about the timing of cessation across gestation and implications for birthweight ( USDHHS 1990 ).

The 2004 Surgeon General’s report, The Health Consequences of Smoking, covered active smoking and disease; and the 2014 Surgeon General’s report, The Health Consequences of Smoking—Fifty Years of Progress, again covered the full range of health consequences of smoking, providing conclusions that drew on data from long-running cohort studies that described how risks change in former smokers up to several decades after quitting. For example, the 2004 report concluded, “Even after many years of not smoking, the risk of lung cancer in former smokers remains higher than in persons who have never smoked” ( USDHHS 2004 , p. 25). In contrast, regarding the effect of smoking in accelerating the decline of lung function, the report determined “[t]he evidence is sufficient to infer a causal relationship between sustained cessation from smoking and a return of the rate of decline in pulmonary function to that of persons who had never smoked” (p. 27). The 2014 report updated estimates of relative risks in former smokers, drawing on more contemporary cohorts, and used the estimates to calculate attributable mortality ( USDHHS 2014 ). The extended follow-up of the cohort studies documented the benefits of cessation by early middle age for reducing the risk of death from any cause.

Coverage of Nicotine and Addiction

The 1964 Surgeon General’s report suggested that smoking was a form of habituation, stating that “[e]ven the most energetic and emotional campaigner against smoking and nicotine could find little support for the view that all those who use tobacco, coffee, tea, and cocoa are in need of mental care even though it may at some time in the future be shown that smokers and nonsmokers have different psychologic characteristics” ( USDHEW 1964 , pp. 351–352). The report used such words as “compulsion” and “habit” but did not consider nicotine to be addicting: “Proof of physical dependence requires demonstration of a characteristic and reproducible abstinence syndrome upon withdrawal of a drug or chemical which occurs spontaneously, inevitably, and is not under control of the subject. Neither nicotine nor tobacco comply with any of these requirements” ( USDHEW 1964 , p. 352). Correspondingly, the report emphasized habituation and not addiction: “The habitual use of tobacco is related primarily to psychological and social drives, reinforced and perpetuated by the pharmacologic actions of nicotine on the central nervous system” ( USDHEW 1964 , p. 354). In 1977, the National Institute on Drug Abuse began to support studies of cigarette smoking as a “dependence process,” comparing it to other drug addictions ( Parascandola 2011 ). The monograph, The Behavioral Aspects of Smoking ( Krasnegor 1979 ), reflected an advancing understanding of the power of nicotine as a pharmacologic agent: “Nicotine has been proposed as the primary incentive in smoking [ Jarvik 1973 , as cited in Krasnegor 1979 ] and may be instrumental in the establishment of the smoking habit. Whether or not it is the only reinforcing agent, it is still the most powerful pharmacological agent in cigarette smoke” (p. 12). The 1979 Surgeon General’s report, Smoking and Health, devoted considerable attention to the behavioral aspects of smoking, but it still did not use the term “addiction” ( USDHEW 1979 ). That report also concluded that there was general acceptance of the existence of a tobacco withdrawal syndrome, which was more prominent in heavy smokers.

“Cigarettes and other forms of tobacco are addicting”;
“Nicotine is the drug in tobacco that causes addiction”; and
“The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine” ( USDHHS 1988 , p. 9).

Later Surgeon General’s reports on tobacco have addressed the subsequent scientific advances in the area of smoking and addiction, particularly the 2010 report on mechanisms by which smoking causes disease ( USDHHS 2010 ).

Perspectives on Smoking Cessation

In 2015, most smokers stated that they wanted to quit smoking (68%), and about 56% of smokers made a serious attempt to quit; however, only about 7% of smokers reported that they had recently quit ( Babb et al. 2017 ). Despite evidence demonstrating that using smoking cessation pharmacotherapy with behavioral support is more effective than quitting without these treatments, most smokers who had recently quit reported that they did not quit with medication or counseling assistance (see Chapter 6 ). Proponents of encouraging smokers to quit without treatment, often called quitting “cold turkey,” point to data indicating that most smokers who quit successfully do so without medications or any type of formal assistance, as well as to population surveys suggesting that cold-turkey quitters do as well or better than those who use over-the-counter NRTs. Proponents of this approach also suggest that medicalization may disempower smokers and create artificial barriers to quitting ( Alpert et al. 2013 ; Polito 2013 ). In contrast, others note that because of a lack of insurance coverage and other barriers, many smokers have little choice but to quit without formal treatment. Selection bias may also play a factor, as the most heavily addicted smokers are those most likely to use NRT , but these smokers also have a lower likelihood of success. In addition, most of those who use NRT do so for short periods of time or at lower-than-recommended doses and do not have adjunctive support available from tobacco cessation quitlines or other interventions ( Amodei and Lamb 2008 ). There are also issues of recall and attribution bias, which may make smokers more likely to report their most proximal experiences with use or nonuse of pharmacologic smoking cessation aids and/or behavioral supports and not to report previous quit attempts during which they used pharmacologic aids and/or behavioral support.

During most of the twentieth century, smokers who wanted to quit had limited resources to do so, especially smokers with mental health or substance use disorders. For example, the investment in research required for behavioral, pharmacologic, and systems-level interventions that increase successful cessation had been relatively limited given the magnitude of tobacco-related disease burden and the size of the population affected ( Dennis 2004 ; Carter et al. 2015 ; Hall et al. 2016 ). Even when interventions developed in the 1980s and 1990s were clearly shown to be effective, most health insurers and health systems showed little interest in providing coverage for or integrating into regular practice any new pharmacologic, behavioral, or systems approaches to cessation (see Chapter 6 ). Additionally, many medical schools provide only a small amount of time, if any, in their academic curriculum or programs for developing clinical skills to train future physicians in addressing tobacco use and dependence in patients ( Ferry et al. 1999 ; Montalto et al. 2004 ; Powers et al. 2004 ; Association of American Medical Colleges 2007 ; Geller et al. 2008 ; Richmond et al. 2009 ; Torabi et al. 2011 ; Griffith et al. 2013 ).

Development and Evolution of a Paradigm for Treating Nicotine Addiction

Clinicians’ views on smoking cessation shifted toward the end of the twentieth century. Given the increasing amount of evidence and awareness of the robust and widespanning beneficial effects of smoking cessation on various chronic diseases ( USDHHS 1990 ), clinicians began to understand that promoting smoking cessation was among the most powerful interventions for increasing health, while merely advising patients to quit was insufficient in promoting smokers to initiate quitting and sustain abstinence without relapsing. Concurrently, researchers began to better understand the powerfully addictive properties of nicotine and the complexities of the nicotine addiction process ( USDHHS 1988 ). This knowledge was disseminated widely to health professionals and the community ( Fiore et al. 1996 ).

Nicotine addiction is now increasingly emphasized as a main driver of both the initiation and continuation of smoking. Thus, the medical community sees the morbidity and mortality associated with smoking as clinical endpoints and nicotine addiction as the cause. Correspondingly, a growing number of intensive behavioral and pharmacologic treatments have become available to promote sustained abstinence.

Epidemiologic Shifts in Smoking Cessation

Chapter 2 provides a detailed discussion of key patterns and trends in cigarette smoking cessation in the United States. It also reviews the changing demographic and smoking-related characteristics of cigarette smokers, with a focus on how these changes may influence future trends in cessation.

Changes in the Patterns of Smoking and Population Characteristics of Smokers

The typical profile of the smoker has evolved over the years. The “hardening hypothesis” suggests that adults who continue to smoke cigarettes in the face of strengthening tobacco control policies and the increasing availability of efficacious cessation interventions will tend to be heavier smokers who are more highly addicted, less interested in quitting, and likely to have more difficulty in quitting ( National Cancer Institute [NCI] 2003 ). Only a limited amount of evidence supports this hypothesis ( Hughes 2011 ). Instead of increases over time in the proportion of smokers with frequent or heavy patterns of smoking, as would be predicted by hardening, the proportion has actually decreased ( Jamal et al. 2016 ). Furthermore, from 2005 to 2015, the percentage of current smokers who were daily smokers declined from 80.8% to 75.7%, and the proportion of current smokers who smoked on only some days (i.e., nondaily smokers) increased from 19.2% to 24.3% ( Jamal et al. 2016 ). Similarly, among daily smokers, the average number of cigarettes smoked per day declined from 16.7 in 2005 to 13.8 in 2014. However, when considering other measures of dependence, some modest and preliminary support exists for hardening among treatment-seeking smokers. For example, in a summary review by Hughes and colleagues (2011) , two of four studies showed increases in dependence and decreases in quit rates, but similar trends were not found among the general population of smokers who had quit.

Reductions in the frequency and heaviness of smoking do not necessarily suggest that a simple continuation of current approaches to increase smoking cessation will increase or even maintain progress in successful quitting. Nondaily or light smokers would be expected to be less addicted to nicotine and, therefore, when motivated to make a cessation attempt, would find it easier to quit than heavier smokers. Still, helping light and nondaily smokers to quit presents challenges. For example, some light and nondaily smokers do not self-identify as smokers, do not believe that they are addicted to nicotine, do not feel that they are at risk of smoking-related health effects, and do not expect quitting to be difficult ( Berg et al. 2013 ; Scott et al. 2015 ; Chaiton et al. 2016 ). The 2008 Clinical Practice Guideline does not recommend cessation medications for use by light smokers, based on insufficient evidence of effectiveness in this population ( Fiore et al. 2008 ). Ten years later, this gap in knowledge about treating light smokers is largely unchanged ( Ebbert et al. 2016 ) (see Chapter 6 ) and presents a barrier for addressing this growing subpopulation of smokers.

The prevalence of smoking is increasingly concentrated in the United States in populations that may face barriers to quitting. These include persons with behavioral health conditions (including mental health conditions or substance use disorders); persons of low socioeconomic status; persons who are lesbian, gay, bisexual, or transgender; American Indians/Alaska Natives; recent immigrants from countries with a high prevalence of smoking; residents of the South and Midwest; and persons with a disability. Such populations have a markedly higher prevalence of cigarette smoking than their respective counterparts, and the decline in the prevalence of smoking in the United States as a whole has been slower among these groups, particularly those with behavioral health conditions and those of lower socioeconomic status ( Grant et al. 2004 ; Schroeder and Morris 2010 ; CDC 2013b , 2016 ; Cook et al. 2014 ; Szatkowski and McNeill 2015 ) (see Chapter 2 ).

Changes in the Products Used by Smokers

The emergence of a wide array of new tobacco products and the increasing use of those products, combined with continued use of other conventional tobacco products, such as menthol cigarettes and smokeless tobacco, could complicate cessation efforts aimed at cigarette smoking ( Trinidad et al. 2010 ; USDHHS 2014 ; Villanti et al. 2016 ; Wang et al. 2016 ). These products include hookahs (water pipes), little cigars and cigarillos, e-cigarettes , and heated tobacco products. Cigarette smokers who also use one or more other tobacco products, generally known as “dual” or “poly” use, have higher dependence on nicotine and greater difficulty quitting ( Wetter et al. 2002 ; Bombard et al. 2007 ; Soule et al. 2015 ).

As of July 26, 2019, 11 states and the District of Columbia have passed laws legalizing nonmedical marijuana use ( National Conference of State Legislatures [NCSL] 2019 ). Although not a tobacco product, marijuana is frequently used in combination with conventional cigarettes or other tobacco products (e. g ., cigars, e-cigarettes ). For example, approximately 70% of adults who are current users of marijuana are also current users of tobacco ( Schauer et al. 2016 ). Results from populationbased surveys and some clinical studies indicate an association between the use of menthol-flavored cigarettes or marijuana and a lower probability of successful quitting ( Ford et al. 2002 ; Patton et al. 2005 ; Gandhi et al. 2009 ; Schauer et al. 2017 ). The available longitudinal evidence from rigorously conducted studies is limited, so it is too soon to determine whether this association is correlational or causal.

Developments in Approaches to Smoking Cessation at the Individual Level

This section summarizes the landmark developments since the 1990 Surgeon General’s report that have shaped treatment for tobacco dependence and corresponding breakthroughs in smoking cessation interventions at the individual level. Chapter 6 provides detailed evidence for current and emerging smoking cessation treatments, adding to the evidence presented in the Clinical Practice Guideline ( Fiore et al. 2008 ). It also explores approaches to increasing the impact of tobacco cessation treatment through improved efficacy and increased reach.

Pharmacotherapy

The scientific understanding of the neurobiologic impact of chronic exposure to nicotine ( USDHHS 2010 ) has stimulated research and development that focuses on identifying novel medications and improving existing medications. The only FDA -approved smoking cessation medication at the time of the 1990 Surgeon General’s report was the gum form of NRT ( USDHHS 1990 ). Since then, several additional NRT formulations (transdermal patch, lozenge, inhaler, and nasal spray) have been developed, with all but the inhaler and spray now approved for over-the-counter sale. Additionally, FDA has approved two non-NRT medications for smoking cessation: bupropion and varenicline ( GlaxoSmithKline 2017 ; FDA 2017 ; Pfizer 2019 ).

Adding to the progress seen for individual agents, favorable developments in pharmacologic treatment have been seen in a variety of other areas over the past two decades. For example, because of the modest efficacy of monotherapy and the recognition that persons with nicotine addiction benefit from intensive treatments, a variety of combination pharmacotherapies have been studied (see Chapter 6 ).

Behavioral Interventions

Discoveries in the behavioral and social sciences have deepened our understanding of psychosocial influences on the nature and treatment of tobacco dependence, which has propelled new approaches to behavioral treatment. The evidence has clarified that during and long after the dissipation of acute pharmacologic withdrawal from nicotine during cessation, several factors—including vacillation of negative emotional states, repeated urges to smoke, diminished motivation, and having less confidence in the ability to successfully quit—can persist throughout the cessation process and undermine quitting ( Liu et al. 2013 ; Ussher et al. 2013 ). Furthermore, encountering environments and situations previously associated with smoking, such as establishments that serve alcohol or interacting with friends who smoke, has been demonstrated to increase risk of relapse ( Conklin et al. 2013 ). Fortunately, behavioral treatment models for mental health conditions and other substance use disorders have been translated and adapted for nicotine addiction to address these factors and have been shown to improve quit rates ( Hall and Prochaska 2009 ).

In addition to quitlines, which have been a longstanding intervention to deliver population-based behavioral smoking cessation support, technological innovations have opened new service delivery platforms for sophisticated behavioral cessation interventions in other modalities. In the 1990s, computer-tailored, in-depth, personalized mailings based on answers to a lengthy questionnaire were developed and tested on smokers; the tailored or personalized mailings were more effective than mailings with standard text ( Prochaska et al. 1993 ; Strecher et al. 1994 ). Receipt of personalized written feedback and self-help materials was also found to increase cessation rates ( Curry et al. 1991 ). A systematic review by the U.S. Preventive Services Task Force (USPSTF) (2015) found self-help materials that were tailored to the individual patient to be effective cessation interventions. Interactive program modalities have been developed and tested ( USPSTF 2015 ) for desktop and laptop computers, first via programs operated from a CD-ROM or hard drive, later via Internet downloads, and more recently from “the cloud” ( Strecher et al. 2005 ; Haskins et al. 2017 ). The current state of science and technology also allows the leveraging of mobile phone technology and applications to deliver cessation interventions ( Whittaker et al. 2016 ). These include applications involving standardized motivation-enhancing texts or quit-promoting strategies—some of which offer real-time, live-peer, or professional advising or counseling within the application ( Smokefree.gov n.d. ). Preliminary evaluations have suggested that these applications may be beneficial to users ( Cole-Lewis et al. 2016 ; Squiers et al. 2016 , 2017 ; Taber et al. 2016 ) and that the cost of delivery is low.

Treating Tobacco Use and Dependence

The 2000 and 2008 Clinical Practice Guidelines had marked impacts on increasing understanding of and operationalizing the current paradigm of treating tobacco use and dependence ( Fiore et al. 2000 , 2008 ). Until the 1990s, synopses of the state of the evidence on smoking cessation usually relied on a somewhat informal aggregation of clinical and population-based studies, an approach that is prone to author bias in the choice of studies included and in their interpretations. Markedly more formal review processes, such as systematic literature reviews, were applied to smoking cessation and treatment in the 1990s and 2000s, as thousands of cessation-related studies accumulated. These more formal reviews systematized the literature review process by using strict criteria for grading studies and employing meta-analyses where appropriate; they also included a more transparent and elaborate process for synthesizing evidentiary findings into conclusions and recommendations.

In addition, the standards and framing of cessation research have evolved over the past several decades, which is consistent with the increased sophistication of pharmaceutical and population-based trials in general. For example, clinical trials have evolved from examining the success rates of persons completing the trial, often examining only the point prevalence of abstinence, into using intent-to-treat, where all persons starting treatment are considered in the denominator and those lost to follow-up are counted as smokers or subject to data imputation techniques ( Hall et al. 2001 ; Mermelstein et al. 2002 ; SRNT Subcommittee on Biochemical Verification 2002 ; Hughes et al. 2003 ; Shiffman et al. 2004 ). Definitions of successful abstinence often examine smoking status at 1 month, 6 months, and 1 year of abstinence after treatment.

Notably, some definitions of successful abstinence allow for brief lapses in smoking cessation to more accurately reflect the natural course of achieving long-term abstinence ( Zhu et al. 1996 ). Similarly, population-level surveillance and research have evolved to include increasingly more complex questions and techniques to more accurately capture the nature of respondents’ use of tobacco products and cessation behavior. For example, sets of questions have been developed to better categorize respondents’ use of healthcare services and the nature of cessation support they received. In addition, new technologies have been deployed to better understand the patterns of behavior among smokers, such as ecological momentary assessment, which cues smokers to provide data on their smoking urges and other thoughts, emotions, and behaviors in real time ( Shiffman 2009 ). Large clinical trials have also examined the interplay between multiple factors that affect quit success, such as different medications, dual-medication therapy, and different approaches and intensities of behavioral interventions ( Redmond et al. 2010 ).

Any level of treatment is beneficial, and more intensive and longer behavioral and pharmacologic treatment is generally better.
Physicians, psychologists, pharmacists, dentists, nurses, and numerous other healthcare professionals can treat nicotine addiction in smokers. Thus, by extension, the various settings in which such professionals work represent appropriate venues for providing these services.
Behavioral interventions and FDA -approved pharmacotherapies are effective for treating nicotine dependence. A combination of behavioral interventions and pharmacotherapy is the optimal treatment based on overwhelming scientific evidence, with superiority in efficacy over either intervention alone.

Advances in research and technology have shaped how the clinical and scientific communities view and approach treatment for nicotine addiction in smokers, but this progress continues to lag the advances made in treating other chronic diseases. For instance, in cancer, cardiovascular disease, and other illnesses with multifactorial etiologies, major strides have been made toward precision treatment methods, which are based on the premise that clinical outcomes can be enhanced by selecting, adapting, and tailoring treatment on the basis of a patient’s specific clinical profile and disease pathogenesis ( Collins and Varmus 2015 ). Such approaches have been endorsed and promoted as part of the Precision Medicine Initiative ( Genetics Home Reference 2018 ), which reinforces that the future of clinical care lies in basic and clinical research and their translation to optimize health outcomes. Although precision treatment has not advanced for smoking cessation at the same rate as it has for treating certain other illnesses, emerging findings suggest that a personalized, precision approach has the potential to meaningfully improve smoking cessation outcomes ( Allenby et al. 2016 ).

Evolution of Approaches to Smoking Cessation at the Population Level

More intensity versus higher reach of support services.

Through the first decades in which cessation interventions were developed, most of the emphasis was on improved efficacy—specifically, increasing the probability that if smokers engaged and fully used an intervention service, their chances of success would be increased. As interventions, both behavioral or pharmacologic therapies and combination therapies have become increasingly effective, but despite the effectiveness of such therapies, they are not being used as designed by substantial numbers of smokers ( Zhu et al. 2012 ). Several theoretical models suggested that efforts to develop interventions need to consider their population impact, not just their individual efficacy for those taking part in the intervention.

Almost no health insurers provided any coverage of smoking treatments—either medications, counseling, or physician intervention.
Most physicians did not systematically address smoking in the course of clinical practice for multiple reasons, including lack of time, perception that patients are unready to quit, limited resources, and inadequate clinical skills related to cessation.
Although smokers generally understood that smoking had unfavorable health effects, many did not fully understand or accept the magnitude or personal relevance of smoking’s effects on various aspects of health and its dramatic overall effect on longevity ( USDHHS 1989 ; Chapman et al. 1993 ). Even if smokers accept the theoretical possibility of risk, they often do not believe that the hypothetical future risk from smoking applies to them personally—for example, they believe they have “good genes” or other healthy habits, or they smoke in a less dangerous manner ( Oakes et al. 2004 ).
Smokers and physicians did not realize that effective treatments were available.
Even when smokers wanted to quit and were potentially interested in getting help, evidence-based treatments were not readily available to them because of financial and practical barriers.

Thus, during the 1980s and 1990s, a series of system and policy innovations were developed and tested to address these barriers. These innovations included the use of organizational system change and quality improvement theory to systematically address opportunities to influence smokers during routine interactions with healthcare systems ( Solberg et al. 1990 ; Manley et al. 1992 ); experiments providing different types of insurance coverage for cessation treatments ( Curry et al. 1998 ); the development of more easily accessible treatments, such as phone-based quitlines ( Orleans et al. 1991 ; Zhu et al. 2012 ); integrated promotion of cessation via mass media campaigns that encouraged the use of cessation services ( McAfee et al. 2013 ); and easily accessible, in-person cessation clinics ( Lee et al. 2016 ).

The lack of accessibility to cessation support was addressed in several ways. One approach attempted to bypass the lack of availability of support within healthcare services by creating easily accessible, low-intensity cessation supports, such as telephone quitlines or in-person clinics, that were generally operated and funded outside the healthcare system. Another approach attempted to integrate very brief but systematic, repeated support for cessation into primary care clinical practices while working to obtain insurance coverage and accessibility to more intense services for those interested in quitting. In some instances, these approaches were combined synergistically ( McAfee et al. 1998 ). A few U.S. states and some other countries, such as the United Kingdom, successfully developed—through funding from tobacco tax dollars or government healthcare—networks of freestanding, in-person cessation clinics that provided basic cessation counseling and medications ( Gibson et al. 2010 ; West et al. 2013 ). However, this model has not been sustained in any geographic region of the United States, primarily because of limited resources to maintain it over time. Still, a higher intensity model, which includes more intensive and comprehensive cessation components, has continued to focus on markedly improving the chances of success by treating nicotine addiction via a tertiary treatment delivery model, akin to how a cancer center approaches patients who are referred for its services. For example, the Mayo Clinic and a handful of similar referral clinics use such strategies as in-depth evaluation by multidisciplinary staff; personalized treatment plans; recurrent follow-up; and, in some cases, admission to a residential facility or hospital ( Hays et al. 2011 ). Although such programs often achieve high rates of smoking cessation, their utility is greatly limited by the high cost of implementation, unclear cost-effectiveness, and limited reach. For example, during a 7-year period, in a study of a large outpatient clinic, 2–3% of smokers used the available nicotine dependence services, even when the services were optimally promoted and delivered ( Burke et al. 2015 ).

Population-Based Interventions

Historically, tobacco control efforts have focused on either helping smokers quit at the individual level, such as through clinical interventions, or on providing population-level interventions to decrease the prevalence of smoking. Potential synergies between these two approaches have become increasingly apparent over the past several decades. This section discusses four examples of attempts to combine individually delivered cessation support and population-based strategies to smoking cessation: quitlines, health systems transformation, mass media campaigns, and health insurance coverage of smoking cessation treatment. Chapter 7 provides a more in-depth review of the current literature on each of these topics and on other population-based interventions that have been shown to promote cessation, such as increasing the prices of tobacco products and the implementation of smokefree policies.

In the late 1980s and throughout the 1990s, researchers interested in helping large numbers of smokers quit smoking began to experiment with the provision of behavioral counseling support via telephone, in the hope of overcoming such barriers to utilization as cost and the reluctance of many smokers to attend face-to-face group or individual sessions. Providing counseling centrally was thought to provide more opportunities for systematically improving the quality of the counseling and the research infrastructures used to answer questions about the cessation process. Protocols were developed and tested in a variety of environments, ranging from academic centers ( Ossip-Klein et al. 1991 ) to health systems ( Orleans et al. 1991 ) to state health departments ( Zhu et al. 1996 ). Multiple large, randomized trials have since established the effectiveness of the telephone modality ( Stead et al. 2013 ). The availability of quitlines grew rapidly during the 1990s and the early 2000s.

The adoption of quitlines by state health departments was initially facilitated by the increased revenue provided to states from the Master Settlement Agreement in 1998 and higher taxes on tobacco products. In 2003, CDC provided supplemental funding to state health departments to establish quitlines in those that did not have them and to enhance quitline services and access in those with existing quitlines ( Zhang et al. 2016 ). In 2004, a national network of state quitlines was created with a single national portal number (1-800-QUIT-NOW), which is serviced by NCI ( Cummins et al. 2007 ; CDC 2014b ). By 2006, residents in all 50 states, the District of Columbia, and U.S. territories had access to quitlines, and the North American Quitline Consortium had been developed to help set evaluation standards and enhance the collection of information, including an agreed-upon minimum dataset to be collected from all callers, with a data warehouse funded by CDC ( North American Quitline Consortium 2007 ; Keller et al. 2010 ). Providers of quitline services grew from modest operations with a few dozen employees to multiple large providers based in a range of organizations, including for-profit and nonprofit national healthcare organizations and academic centers, some employing hundreds of “quit coaches.”

Mass Media Campaigns

Mass media educational campaigns on the hazards of smoking have been used for decades, in part to motivate quit attempts in the general population of current smokers, and a considerable evidence base shows their effectiveness in promoting successful cessation at the population level ( NCI 2008 ; USDHHS 2014 ). These campaigns are generally thought of as being unrelated to efforts to provide direct assistance and support to individual smokers in healthcare settings or through community initiatives. However, since 1990, numerous efforts have been made to create synergies and efficiencies between mass media campaigns and the provision of individual support for quit attempts. For example, CDC ’s Tips From Former Smokers (Tips) media campaign features ads with real people (former smokers) who have suffered the health consequences of smoking to increase awareness of suffering caused by smoking. The ads are also tagged with a quitline number ( CDC 2012 , 2013a ). Tagging the ads with an offer of assistance may help smokers absorb the message of the ad by making it actionable rather than simply negative. Chapter 7 discusses the effectiveness of mass media campaigns, including Tips .

Healthcare Systems

Clinic-based integration of health systems.

Ask: Systematically identify the smoking status of all patients flowing through a practice, usually by an assistant interviewing the patient rather than relying on physician recall of patients’ smoking status at every visit;
Advise: Provide at every encounter very brief, non-threatening recommendations to quit;
Assist: Offer practical help for quitting, including tips to make it through the first few weeks and brief supportive counseling; and
Arrange: Ensure that any smoker planning a quit attempt will receive follow-up (e. g ., during future office visits and/or through off-site resources).

Despite being shown to have significant benefits to smokers in clinical practices in the 1980s and 1990s, the adoption, implementation, and subsequent maintenance of this systematic approach was slow and uneven ( Ferketich et al. 2006 ).

Based on an additional review of the evidence ( Fiore et al. 2008 ), a fifth step, “Assess,” was added between the “Advise” and “Assist” components, thereby emphasizing the importance of determining a patient’s level of interest in quitting so that assistance and follow-up could be tailored to that person’s specific circumstances. For example, a brief interaction with a patient not interested in quitting would focus on enhancing motivation rather than providing quit advice.

The 5 A’s model is an example of an intervention designed to maximize the probability of a smoker making a quit attempt and the probability that he or she will be successful during such an attempt. The model seeks to accomplish these two tasks for a population of smokers. Building on the effectiveness of the 5 A’s model, the Ask, Advise, Refer ( AAR ) model was developed as a shorter alternative to the 5 A’s model in clinical settings where there is less time afforded for the patient encounter ( Schroeder 2005 ). In addition, a different model, termed Ask, Advise, Connect ( AAC ) ( Vidrine et al. 2013 ) was developed to ameliorate the low rate of participation among persons passively referred to a smoking cessation treatment, usually a quitline, through the AAR model. In the AAC model, smokers who accept the referral are subsequently contacted by the provider of smoking cessation treatment, typically a quitline counselor. The referral or connection services, such as to quitlines, have very strong evidence for effectiveness ( Vidrine et al. 2013 ; Adsit et al. 2014 ) (also see Chapter 7 ). However, fewer studies have assessed the overall population impact of the AAR and AAC models compared with the 4 A’s and 5 A’s models.

Lack of time;
Lack of reliable reimbursement for provision of services;
Lack of acceptance that addressing tobacco dependence is part of a physician’s job;
Lack of training and/or comfort addressing problems with substance abuse;
Lack of reliable, accessible referral resources;
High prevalence of smoking, meaning that even brief interventions significantly affect clinic flow, as the interventions may need to be implemented with a large number of patients ( Vogt et al. 2005 ; Association of American Medical Colleges 2007 ; Blumenthal 2007 ); and
Privacy concerns, fear of losing patients, the discouraging belief that most patients will not be able to stop, and concern about stigmatizing the smoker ( Schroeder 2005 ).

In recent years, increased attention has also been paid to the importance of building linkages between public health and the healthcare system and between community and clinical healthcare resources. This draws on the recognition that public health and healthcare stakeholders have complementary strengths and perspectives; that ultimately achieving lasting improvements in population health will take the combined efforts of both; and that improved coordination efforts will hasten this outcome. As part of this broader trend, national public health organizations and state tobacco control programs have begun to engage with healthcare systems to encourage and help them integrate treatment for tobacco dependence into their workflows ( CDC 2006 ). Some healthcare systems have broadened the scope of their interventions to address upstream factors that shape health outcomes. For example, some healthcare systems have championed evidence-based interventions that go beyond the clinical sphere, such as smokefree and tobacco-free policies, increases in the price of tobacco products, and policies raising the age of sale for tobacco products to 21 years ( Campaign for Tobacco-Free Kids 2016 ). Predicting the evolution of cessation treatment in the United States and the various roles of different segments of the healthcare system is challenging because of the volatility and uncertain future structure of healthcare, especially the nature of healthcare insurance. Regardless of what type of delivery system emerges, efforts should continue to integrate evidence-based tobacco treatment and cessation supports into healthcare settings and expand those supports. This would require further embedding of smoking processes and outcomes in quality measures, adequate funding, and routinization of training. Such services could be provided in the general healthcare system, as well as through specialized cessation clinics. The ability to deliver services effectively would be aided by having sufficient geographic locations for delivering care, promoting services, and removing barriers to services.

Health Insurance Coverage

Comprehensive insurance coverage for evidencebased cessation treatments plays a key role in helping smokers quit by increasing their access to proven treatments that raise their chances of quitting successfully ( Fiore et al. 2008 ; CDC 2014a ). Research in multiple healthcare settings in the 1990s ( Curry et al. 1998 ) and 2000s ( Joyce et al. 2008 ; Hamlett-Berry et al. 2009 ; Smith et al. 2010 ; Fu et al. 2014 ; Fu et al. 2016 ) has demonstrated that comprehensive cessation coverage increases quit attempts, the use of cessation treatments, and successful quitting ( Fiore et al. 2008 ). Accordingly, implementation of comprehensive cessation coverage is important in both private and public health insurance.

Significant milestones in the recognition that comprehensive insurance coverage for smoking cessation plays a key role in helping smokers quit include (a) the Community Preventive Services Task Force’s finding that reducing tobacco users’ out-of-pocket costs for proven cessation treatments increases the number of tobacco users who quit ( Hopkins et al. 2001 ), and (b) the recommendation in each of the Clinical Practice Guidelines that health insurers cover the FDA -approved cessation treatments and the behavioral treatments that the Guidelines found to be effective ( Fiore et al. 2000 , 2008 ). These recommendations draw on a body of research that has documented the outcomes of insurance coverage for cessation, including its cost-effectiveness. This research has also helped to identify the levels of coverage that influence tobacco cessation. More recently, several studies have examined the utilization of cessation treatments covered by health insurance, especially cessation medications, and how this has changed over time. Initial findings from these analyses suggest that cessation treatments continue to be underused, especially among Medicaid populations, and utilization varies considerably across states ( Babb et al. 2017 ).

Healthcare Insurance Policies

After 2010, several national levers were added to make tobacco use and dependence treatment a part of healthcare. Both Medicare and Medicaid required coverage of certain smoking cessation treatments, and the Affordable Care Act included several provisions that required non-grandfathered commercial health plans to provide in-network smoking cessation medications and counseling without financial barriers because those two treatments had “A” ratings from USPSTF ( McAfee et al. 2015 ). Even with these new regulatory levers, many national plans are not yet providing the required coverage ( Kofman et al. 2012 ). Chapter 7 provides an in-depth discussion of private and public health insurance coverage for the treatment of tobacco use and dependence.

E-Cigarettes: Potential Impact on Smoking Cessation

E-cigarettes (also called electronic nicotine delivery systems [ ENDS ], vapes, vape pens, tanks, mods, and podmods) are battery-powered devices designed to convert a liquid (often called e-liquid)—which contains a humectant (propylene glycol and vegetable glycerin) and also typically contains nicotine, flavorings, and other compounds— into aerosol for inhalation by the user. First introduced in the United States in 2007 ( USDHHS 2016 ), the advent of e-cigarettes into the tobacco product marketplace was seen by some as a potential harm-reduction tool for current adult smokers if the products were used to transition completely from conventional cigarettes ( Fagerstrom et al. 2015 ; Warner and Mendez 2019 ). E-cigarette aerosol has been shown to contain markedly lower levels of harmful constituents than conventional cigarette smoke ( National Academies of Sciences, Engineering, and Medicine 2018 ). Accordingly, interest remains in policies and approaches that could maximize potential benefits of these devices while minimizing potential pitfalls posed by the devices at the individual and population levels, including concerns about initiation among young people. The 2016 Surgeon General’s report, E-Cigarette Use Among Youth and Young Adults, examined many aspects of e-cigarettes related to young people; however, it did not address the potential impact of e-cigarettes on smoking cessation among adult smokers ( USDHHS 2016 ). It is also important to note that the landscape of available e-cigarette products has rapidly diversified since their introduction in the United States in 2007, including the introduction of “pod mod” e-cigarettes that have dominated the e-cigarette marketplace in recent years ( Barrington-Trimis and Leventhal 2018 ; Office of the U.S. Surgeon General n.d. ). This section highlights salient issues about how e-cigarettes may influence cessation, which is reviewed in more depth in Chapter 6 .

Implications of E-Cigarette Characteristics for Smoking Cessation

Nicotine delivery through inhalation, as is the case with cigarette smoking, results in rapid nicotine absorption and delivery to the brain. The pharmacokinetics of nicotine delivery varies across products and is influenced by user topography, with some, but not all, e-cigarette products providing nicotine delivery comparable to conventional cigarettes ( National Academies of Sciences, Engineering, and Medicine 2018 ). By contrast, the nicotine inhaler, one of several FDA -approved NRTs, delivers nicotine primarily through the buccal mucosa; it is designed to reduce nicotine withdrawal and cravings while minimizing abuse liability ( Schneider et al. 2001 ). For smokers of conventional cigarettes who seek a product with a rapid delivery of nicotine similar to cigarettes, e-cigarettes that deliver nicotine in a similar way to cigarettes may have greater appeal than NRTs. Although rapid boluses of nicotine could increase the appeal, as well as addiction and potential greater abuse liability, of e-cigarettes relative to NRTs, whether this pharmacokinetic profile produces an effective method of cessation is presently inconclusive from the emerging base of empirical evidence ( Shihadeh and Eissenberg 2015 ).

Other features of e-cigarettes that may enhance their appeal to smokers of conventional cigarettes include the ways in which they mirror some of the sensorimotor features of conventional cigarette smoking, including stimulation of the airways, the sensations and taste of e-cigarette aerosol in the mouth and lungs, the hand-to-mouth movements and puffing in which e-cigarette users engage, and the exhalation of aerosol that may visually resemble cigarette smoking. Given the potentially important role of such sensorimotor factors in the reinforcing and addictive qualities of conventional cigarettes ( Chaudhri et al. 2006 ), the presence of these attributes could make e-cigarettes more appealing to smokers as a substitute for cigarettes than NRTs because the NRTs either lack such sensorimotor features (e. g ., the transdermal patch, nicotine gum) or offer only partial approximations (e.g., the inhaler).

However, when considering e-cigarettes as a potential cessation aid for adult smokers, it is also important to take into account factors related to both safety and efficacy. NRT has been proven safe and effective, but there is no safe tobacco product. Although e-cigarette aerosol generally contains fewer toxic chemicals than conventional cigarette smoke, all tobacco products, including e-cigarettes, carry risks.

As noted in the 2016 Surgeon General’s report, many of the characteristics that distinguish e-cigarettes from conventional cigarettes increase the appeal of these new products to youth and young adults, particularly nonsmokers ( USDHHS 2016 ). These factors include appealing flavors, high concentrations of nicotine, concealability of use, and widespread marketing through social media promotion and other channels ( Barrington-Trimis and Leventhal 2018 ). Many e-cigarettes differ markedly in shape and feel compared with conventional cigarettes; e-cigarettes come in a variety of shapes, including rectangular tank-style and USB-shaped devices (as discussed in Chapter 6 and shown in Figure 6.1 ). For example, JUUL, the top-selling e-cigarette brand in the United States in 2018 ( Wells Fargo Securities 2018 ), is shaped like a USB flash drive and offers high concentrations of nicotine in the cartridges, which are also known as “pods” ( Huang et al. 2018 ). Notably, the novelty, diversity, and customizability of e-cigarettes appeal to youth ( Chu et al. 2017 ; Office of the U.S. Surgeon General n.d. ). For example, there are numerous scientific reports documenting the appeal of, and dramatic rise in, JUUL use among youth and young adults ( Chen 2017 ; Teitell 2017 ; Beal 2018 ; Bertholdo 2018 ; Coughlin 2018 ; Grigorian 2018 ; Saggio 2018 ; Suiters 2018 ; FDA 2018 ; Willett et al. 2018 ; Radding n.d. ).

Of note, a growing number of e-cigarettes , including JUUL, also use nicotine salts, which have a lower pH than the freebase nicotine used in most other e-cigarettes and traditional tobacco products, and allow particularly high levels of nicotine to be inhaled more easily and with less irritation. Although this type of product may be appealing to adult smokers seeking e-cigarettes with potentially greater nicotine delivery, the potency and appeal of such products can also make it easier for young people to initiate the use of nicotine and become addicted ( Office of the U.S. Surgeon General n.d. ).

The final chapter of the 2014 Surgeon General’s report concluded that the use of e-cigarettes could have both positive and negative impacts at the individual and population levels ( USDHHS 2014 ). One of its conclusions was that “the promotion of noncombustible products is much more likely to provide public health benefits only in an environment where the appeal, accessibility, promotion, and use of cigarettes and other combusted tobacco products are being rapidly reduced” ( USDHHS 2014 , p. 874). Therefore, it is important to continue (a) monitoring the findings of research on the potential of e-cigarettes as a smoking cessation aid and (b) evaluating the positive and negative impacts that these products could have at the individual and population levels, so as to ensure that any potential benefits among adult smokers are not offset at the population level by the already marked increases in the use of these products by youth. It is particularly important to evaluate scientific evidence on the impact of e-cigarettes on adult smoking cessation in the current context of the high level of e-cigarette use by youth, which increased at unprecedented levels in recent years following the introduction of JUUL and other e-cigarettes shaped like USB flash drives ( Cullen et al. 2019 ).

Once erroneously considered a habit that could be broken by simply deciding to stop, nicotine addiction is now recognized as a chronic, relapsing condition. The prevalence of cigarette smoking in the United States has declined steadily since the 1960s; however, as of 2017, there were still more than 34 million adult current cigarette smokers in the United States ( Wang et al. 2018 ).

Proven smoking cessation treatments are widely available today. However, the reach and use of existing smoking cessation interventions remain low, with less than one-third of smokers using any proven cessation treatments (behavioral counseling and/or medication) ( Babb et al. 2017 ). A majority of smokers still attempt to quit without using such treatments, contributing to a failure rate in excess of 90% ( Hughes et al. 2004 ; Fiore et al. 2008 ).

Medications and behavioral interventions with increasing levels of efficacy and sophistication are becoming more widely available, but there is considerable room for improvement. Further, the challenge of getting behavioral and pharmacologic interventions to be used concurrently and disseminated more broadly to the public has only been partially solved.

Full integration of treatment for nicotine dependence into all clinical settings—including primary and specialty clinics, hospitals, and cancer treatment settings—can benefit from increases in barrier-free health insurance coverage. Combining health service systems and electronic media platforms for the delivery of smoking cessation interventions has emerged as one promising method to increase reach of smoking cessation treatment to smokers (e. g ., evidence-based cessation interventions using phone lines and mobile phone applications, and use of electronic health records to promote more timely referral to cessation support services). Barrier-free health insurance coverage (e.g., copays, coverage limits, prior authorization) and access to services, coupled with the use of quality improvement metrics and methodologies, have been shown to increase smokers’ use of evidencebased services.

Clinical-, system-, and population-level strategies are increasingly taking a more holistic approach to decreasing the prevalence of smoking, with interventions designed to increase quit attempts and enhance the chances of success. Examples include the national Tips From Former Smokers media campaign, which used ads featuring smokers who had suffered tobacco-related morbidity to increase awareness of individual suffering caused by smoking while simultaneously enhancing the capacity of the national quitline network to respond to upsurges in calls that were generated by tagging the ads with the phone number for the quitline. Millions of smokers made quit attempts as a result of exposure to the ads, and hundreds of thousands have successfully quit smoking. In addition, the development and dissemination of the carefully crafted and research-tested 5 A’s model in healthcare settings, combined with public and private policy changes that encourage coverage of cessation, have systematically encouraged more smokers to try to quit and provided them with evidence-based support. Still, the potential of mass media campaigns, quitlines, and clinical support has been tapped only partially, leaving many opportunities for further adoption, dissemination, and extensions of these approaches.

Use of e-cigarettes could have varied impacts on different segments of the population, including potential benefits to current adult cigarette smokers who transition completely; however, potential efficacy may depend on many factors, such as type of devices and e-liquids used, reason for use, and duration of use. Well-controlled, randomized clinical trials and rigorous, large-scale observational studies with long-term follow-ups will be critical to better understand the impact of e-cigarettes on cessation under various conditions and settings. Nevertheless, the potential benefit of e-cigarettes for cessation among adult smokers cannot come at the expense of escalating rates of use of these products by youth. Accordingly, the current science base supports a number of actions to minimize population risks while continuing to explore the potential utility of e-cigarettes for cessation, including efforts to prevent e-cigarette use among young people, regulate e-cigarette products and marketing, and discourage longterm use of e-cigarettes as a partial substitute for conventional cigarettes rather than completely quitting.

References 1

Adsit RT, Fox BM, Tsiolis T, Ogland C, Simerson M, Vind LM, Bell SM, Skora AD, Baker TB, Fiore MC. Using the electronic health record to connect primary care patients to evidence-based telephonic tobacco quitline services: a closed-loop demonstration project. Translational Behavioral Medicine 2014;4(3):324–32. [ PMC free article : PMC4167898 ] [ PubMed : 25264471 ]
Allenby CE, Boylan KA, Lerman C, Falcone M. Precision medicine for tobacco dependence: development and validation of the nicotine metabolite ratio. Journal of Neuroimmune Pharmacology 2016;11(3):471–83. [ PMC free article : PMC5479354 ] [ PubMed : 26872457 ]
Alpert HR, Connolly GN, Biener L. A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation. Tobacco Control 2013;22(1):32–7. [ PubMed : 22234781 ]
American Psychiatric Association. Substance-related and addictive disorders. In: Diagnostic and Statistical Manual of Mental Disorders . 5th ed. Arlington (VA): American Psychiatric Association Publishing, 2013.
Amodei N, Lamb RJ. Over-the-counter nicotine replacement therapy: can its impact on smoking cessation be enhanced? Psychology of Addictive Behaviors 2008;22(4):472–85. [ PMC free article : PMC3577424 ] [ PubMed : 19071972 ]
Association of American Medical Colleges. Physician Behavior and Practice Patterns Related to Smoking Cessation . Washington (DC): Association of American Medical Colleges, 2007.
Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting smoking among adults—United States, 2000–2015. Morbidity and Mortality Weekly Report 2017;65(52):1457–64. [ PubMed : 28056007 ]
Barrington-Trimis JL, Leventhal AM. Adolescents’ use of “pod mod” e-cigarettes—urgent concerns. New England Journal of Medicine 2018;379(12):1099–102. [ PMC free article : PMC7489756 ] [ PubMed : 30134127 ]
Bartsch AL, Harter M, Niedrich J, Brutt AL, Buchholz A. A systematic literature review of self-reported smoking cessation counseling by primary care physicians. PLoS One 2016;11(12):e0168482. [ PMC free article : PMC5176294 ] [ PubMed : 28002498 ]
Beal K. JUUL e-cigarettes make their way into local schools, February 8, 2018; < http://wset .com/news /local/juul-e-cigarettes-make-their-way-into-local-schools >; accessed: August 9, 2018.
Berg CJ, Schauer GL, Buchanan TS, Sterling K, DeSisto C, Pinsker EA, Ahluwalia JS. Perceptions of addiction, attempts to quit, and successful quitting in nondaily and daily smokers. Psychology of Addictive Behaviors 2013;27(4):1059–67. [ PMC free article : PMC4030671 ] [ PubMed : 24364689 ]
Bertholdo S. Vaping goes mainstream: high tech devices especially popular on local campuses. The Acorn, February 1, 2018; < https://www .theacorn .com/articles/vaping-goes-mainstream/ >; accessed: August 9, 2018.
Blumenthal DS. Barriers to the provision of smoking cessation services reported by clinicians in underserved communities. Journal of the American Board of Family Medicine 2007;20(3):272–9. [ PubMed : 17478660 ]
Bombard JM, Pederson LL, Nelson DE, Malarcher AM. Are smokers only using cigarettes? exploring current polytobacco use among an adult population. Addictive Behaviors 2007;32(10):2411–9. [ PubMed : 17490825 ]
Burke MV, Ebbert JO, Schroeder DR, McFadden DD, Hays JT. Treatment outcomes from a specialist model for treating tobacco use disorder in a medical center. Medicine 2015;94(44):e1903. [ PMC free article : PMC4915890 ] [ PubMed : 26554789 ]
Campaign for Tobacco-Free Kids. Trinity Health and Campaign for Tobacco-Free Kids partner to reduce tobacco use with focus on raising tobacco age to 21 [press release], April 28 2016; < https://www .tobaccofreekids .org/press_releases /post/2016_04_28_trinity >; accessed: September 14, 2017.
Carter AJ, Delarosa B, Hur H. An analysis of discrepancies between United Kingdom cancer research funding and societal burden and a comparison to previous and United States values. Health Research Policy and Systems 2015;13:62. [ PMC free article : PMC4629288 ] [ PubMed : 26526609 ]
Centers for Disease Control and Prevention. A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment . Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006.
Centers for Disease Control and Prevention. Increases in quitline calls and smoking cessation website visitors during a national tobacco education campaign—March 19–June 10, 2012. Morbidity and Mortality Weekly Report 2012;61(34):667–70. [ PubMed : 22932300 ]
Centers for Disease Control and Prevention. Impact of a national tobacco education campaign on weekly numbers of quitline calls and website visitors—United States, March 4–June 23, 2013. Morbidity and Mortality Weekly Report 2013a;62(37):763–7. [ PMC free article : PMC4585359 ] [ PubMed : 24048152 ]
Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged ≥18 years with mental illness—United States, 2009–2011. Morbidity and Mortality Weekly Report 2013b;62:81–7. [ PMC free article : PMC4604817 ] [ PubMed : 23388551 ]
Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2014 . Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014a; < https://www .cdc.gov/tobacco /stateandcommunity /best_practices /pdfs/2014/comprehensive.pdf >; accessed: July 26, 2017.
Centers for Disease Control and Prevention. Frequently asked questions (FAQ) about 1-800-QUIT-NOW and the National Network of Tobacco Cessation Quitlines, May 2014b; < https://www .cdc.gov/tobacco /quit_smoking /cessation/pdfs/1800quitnow_faq.pdf >; accessed: April 4, 2018.
Centers for Disease Control and Prevention. Current cigarette smoking among adults in the United States, December 1, 2016; < https://www .cdc.gov/tobacco /data_statistics /fact_sheets/adult_data /cig_smoking/index.htm >; accessed: September 7, 2017.
Chaiton M, Cohen JE, Bondy SJ, Selby P, Brown KS, Ferrence R, Garcia JM. Perceived addiction as a predictor of smoking cessation among occasional smokers. Journal of Smoking Cessation 2016:1–8.
Chapman S, Wong WL, Smith W. Self-exempting beliefs about smoking and health: differences between smokers and ex-smokers. American Journal of Public Health 1993;83(2):215–9. [ PMC free article : PMC1694573 ] [ PubMed : 8427326 ]
Chaudhri N, Caggiula AR, Donny EC, Palmatier MI, Liu X, Sved AF. Complex interactions between nicotine and nonpharmacological stimuli reveal multiple roles for nicotine in reinforcement. Psychopharmacology 2006;184(3-4):353–66. [ PubMed : 16240165 ]
Chen A. Teenagers embrace JUUL, saying it’s discreet enough to vape in class, December 4, 2017; < https://www .npr.org/sections /health-shots /2017/12/04/568273801 /teenagers-embrace-juul-saying-its-discreet-enough-to-vape-in-class >; accessed: August 9, 2018.
Chu K, Allem J, Cruz TB, Unger JB. Vaping on Instagram: cloud chasing, hand checks and product placement. Tobacco Control 2017;26:575–8. [ PMC free article : PMC5362347 ] [ PubMed : 27660111 ]
Cole-Lewis H, Augustson E, Sanders A, Schwarz M, Geng Y, Coa K, Hunt Y. Analysing user-reported data for enhancement of SmokefreeTXT: a national text message smoking cessation intervention. Tobacco Control 2016. [ PubMed : 27852892 ]
Collins FS, Varmus H. A new initiative on precision medicine. New England Journal of Medicine 2015;372(9):793–5. [ PMC free article : PMC5101938 ] [ PubMed : 25635347 ]
Conklin CA, Salkeld RP, Perkins KA, Robin N. Do people serve as cues to smoke? Nicotine and Tobacco Research 2013;15(12):2081–7. [ PMC free article : PMC3819981 ] [ PubMed : 23873978 ]
Cook BL, Wayne GF, Kafali EN, Liu Z, Shu C, Flores M. Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation. JAMA: the Journal of the American Medical Association 2014;311(2):172–82. [ PMC free article : PMC5555156 ] [ PubMed : 24399556 ]
Corey CG, Chang JT, Rostron BL. Electronic nicotine delivery system (ENDS) battery-related burns presenting to US emergency departments, 2016. Injury Epidemiology 2018;5(1):4. [ PMC free article : PMC5835487 ] [ PubMed : 29504085 ]
Coughlin S. We asked teens to explain Juuling to us & wow, August 9, 2018; < http://www .refinery29 .com/2018/02/190089 /what-is-juul-e-cigarette-vaping-teenagers >.
Creamer MR, Wang TW, Babb S, Cullen KA, Day H, Willis G. Tobacco product use and cessation indicators among adults—United States, 2018. Morbidity and Mortality Weekly Report 2019;68(45):1013–9. [ PMC free article : PMC6855510 ] [ PubMed : 31725711 ]
Cullen KA, Gentzke AS, Sawdey MD, Chang JT, Anic GM, Wang TW, Creamer MR, Jamal A, Ambrose BK, King BA. E-cigarette use among youth in the United States, 2019. JAMA: the Journal of the American Medical Association 2019. [ PMC free article : PMC6865299 ] [ PubMed : 31688912 ]
Cummins SE, Bailey L, Campbell S, Koon-Kirby C, Zhu SH. Tobacco cessation quitlines in North America: a descriptive study. Tobacco Control 2007;16:(Suppl 1):i9–i15. [ PMC free article : PMC2598516 ] [ PubMed : 18048639 ]
Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization. New England Journal of Medicine 1998;339(10):673–9. [ PubMed : 9725926 ]
Curry SJ, Wagner EH, Grothaus LC. Evaluation of intrinsic and extrinsic motivation interventions with a self-help smoking cessation program. Journal of Consulting and Clinical Psychology 1991;59(2):318–24. [ PubMed : 2030194 ]
Dennis PA. Disparities in cancer funding. Science 2004;305(5689):1401–2. [ PubMed : 15353780 ]
Ebbert JO, Croghan IT, Hurt RT, Schroeder DR, Hays JT. Varenicline for smoking cessation in light smokers. Nicotine and Tobacco Research 2016;18(10):2031–5. [ PMC free article : PMC6280997 ] [ PubMed : 27117285 ]
Elias J, Hendlin YH, Ling PM. Public versus internal conceptions of addiction: an analysis of internal Philip Morris documents. PLoS Medicine 2018;15(5):e1002562. [ PMC free article : PMC5929514 ] [ PubMed : 29715300 ]
Fagerstrom K, Etter JF, Unger JB. E-cigarettes: a disruptive technology that revolutionizes our field? Nicotine and Tobacco Research 2015;17(2):125–6. [ PMC free article : PMC4892710 ] [ PubMed : 25609846 ]
Farber HJ, Neptune ER, Ewart GW. Corrective statements from the tobacco industry: more evidence for why we need effective tobacco control. Annals of the American Thoracic Society 2018;15(2):127–30. [ PubMed : 29140104 ]
Ferketich AK, Khan Y, Wewers ME. Are physicians asking about tobacco use and assisting with cessation? Results from the 2001–2004 national ambulatory medical care survey (NAMCS). Preventive Medicine 2006;43(6):472–6. [ PubMed : 16920185 ]
Ferry LH, Grissino LM, Runfola PS. Tobacco dependence curricula in U.S. undergraduate medical education. JAMA: the Journal of the American Medical Association 1999;282(9):825–9. [ PubMed : 10478687 ]
Fiore MC, Bailey WC, Cohen SJ. Treating Tobacco Use and Dependence: Clinical Practice Guideline . Rockville (MD): U.S. Department of Health and Human Services, U.S. Public Health Service, 2000.
Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER, Heyman RB, Holbrook J, Jaen CR, Kottke TE, et al. Smoking Cessation: Clinical Practice Guideline No. 18 . Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1996. AHCPR Publication No. 96-0692.
Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, Dorfman SF, Froelicher ES, Goldstein MG, Healton CG, et al. Treating Tobacco Use and Dependence: 2008 Update. U.S. Public Health Service Clinical Practice Guideline . Rockville (MD): U.S. Department of Health and Human Services, 2008.
Fiore MC, Novotny TE, Pierce JP, Giovino GA, Hatziandreu EJ, Newcomb PA, Surawicz TS, Davis RM. Methods used to quit smoking in the United States. Do cessation programs help? JAMA: the Journal of the American Medical Association 1990;263(20):2760–5. [ PubMed : 2271019 ]
Ford DE, Vu HT, Anthony JC. Marijuana use and cessation of tobacco smoking in adults from a community sample. Drug and Alcohol Dependence 2002;67(3):243–8. [ PubMed : 12127195 ]
Friedman LC, Cheyne A, Givelber D, Gottlieb MA, Daynard RA. Tobacco industry use of personal responsibility rhetoric in public relations and litigation: disguising freedom to blame as freedom of choice. American Journal of Public Health 2015;105(2):250–60. [ PMC free article : PMC4318333 ] [ PubMed : 25521876 ]
Fu SS, van RynM, Nelson D, Burgess DJ, Thomas JL, Saul J, Clothier B, Nyman JA, Hammett P, Joseph AM. Proactive tobacco treatment offering free nicotine replacement therapy and telephone counselling for socioeconomically disadvantaged smokers: a randomised clinical trial. Thorax 2016;71(5):446–53. [ PMC free article : PMC4862067 ] [ PubMed : 26931362 ]
Fu SS, van Ryn M, Sherman SE, Burgess DJ, Noorbaloochi S, Clothier B, Taylor BC, Schlede CM, Burke RS, Joseph AM. Proactive tobacco treatment and population-level cessation: a pragmatic randomized clinical trial. JAMA Internal Medicine 2014;174(5):671–7. [ PubMed : 24615217 ]
Gandhi KK, Foulds J, Steinberg MB, Lu SE, Williams JM. Lower quit rates among African American and Latino menthol cigarette smokers at a tobacco treatment clinic. International Journal of Clinical Practice 2009;63(3):360–7. [ PubMed : 19222622 ]
Geller AC, Brooks DR, Powers CA, Brooks KR, Rigotti NA, Bognar B, McIntosh S, Zapka J. Tobacco cessation and prevention practices reported by second and fourth year students at U.S. medical schools. Journal of General Internal Medicine 2008;23(7):1071–6. [ PMC free article : PMC2517923 ] [ PubMed : 18612747 ]
Genetics Home Reference. What is the Precision Medicine Initiative, June 12, 2018; < https://ghr .nlm.nih.gov /primer/precisionmedicine/initiative >; accessed: June 13, 2018.
Ghorai K, Akter S, Khatun F, Ray P. mHealth for smoking cessation programs: a systematic review. Journal of Personalized Medicine 2014;4(3):412–23. [ PMC free article : PMC4263966 ] [ PubMed : 25563359 ]
Gibson JE, Murray RL, Borland R, Cummings KM, Fong GT, Hammond D, McNeill A. The impact of the United Kingdom’s national smoking cessation strategy on quit attempts and use of cessation services: findings from the International Tobacco Control Four Country Survey. Nicotine and Tobacco Research 2010;12(Suppl):S64–S71. [ PMC free article : PMC2948139 ] [ PubMed : 20889483 ]
GlaxoSmithKline. Medication guide: Wellbutrin (bupropion hydrochloride) tablets, May 2017; < https://www .gsksource .com/pharma/content /dam/GlaxoSmithKline /US/en/Prescribing_Information /Wellbutrin_Tablets /pdf/WELLBUTRIN-TABLETS-PI-MG .PDF >; accessed: July 16, 2019.
Grant BF, Hasin DS, Chou SP, Stinson FS, Dawson DA. Nicotine dependence and psychiatric disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry 2004;61(11):1107–15. [ PubMed : 15520358 ]
Griffith BN, Montalto NJ, Ridpath L, Sullivan K. Tobacco dependence curricula in U.S. osteopathic medical schools: a follow-up study. Journal of the American Osteopathic Association 2013;113(11):838–48. [ PubMed : 24174505 ]
Grigorian G. Juuling at Dartmouth: addiction renewed and reimagined. The Dartmouth , February 9, 2018; < http://www .thedartmouth .com/article/2018 /02/juuling-at-dartmouth-addiction-renewed-and-reimagined >; accessed: August 9, 2018.
Hajek P, Stead LF, West R, Jarvis M, Hartmann-Boyce J, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003999. DOI: 10.1002/14651858.CD003999.pub4. [ PubMed : 23963584 ] [ CrossRef ]
Hall M, Bogdanovica I, Britton J. Research funding for addressing tobacco-related disease: an analysis of UK investment between 2008 and 2012. BMJ Open 2016;6(7):e011609. [ PMC free article : PMC4947797 ] [ PubMed : 27377637 ]
Hall SM, Delucchi KL, Velicer WF, Kahler CW, RangerMoore J, Hedeker D, Tsoh JY, Niaura R. Statistical analysis of randomized trials in tobacco treatment: longitudinal designs with dichotomous outcome. Nicotine and Tobacco Research 2001;3(3):193–202. [ PubMed : 11506764 ]
Hall SM, Prochaska JJ. Treatment of smokers with cooccurring disorders: emphasis on integration in mental health and addiction treatment settings. Annual Review of Clinical Psychology 2009;5:409–31. [ PMC free article : PMC2718730 ] [ PubMed : 19327035 ]
Hamlett-Berry K, Davison J, Kivlahan DR, Matthews MH, Hendrickson JE, Almenoff PL. Evidence-based national initiatives to address tobacco use as a public health priority in the Veterans Health Administration. Military Medicine 2009;174(1):29–34. [ PubMed : 19216295 ]
Haskins BL, Lesperance D, Gibbons P, Boudreaux ED. A systematic review of smartphone applications for smoking cessation. Translational Behavioral Medicine 2017;7(2):292–9. [ PMC free article : PMC5526818 ] [ PubMed : 28527027 ]
Hays JT, Croghan IT, Schroeder DR, Burke MV, Ebbert JO, McFadden DD, Hurt RD. Residential treatment compared with outpatient treatment for tobacco use and dependence. Mayo Clinic Proceedings 2011;86(3):203–9. [ PMC free article : PMC3046940 ] [ PubMed : 21307389 ]
Hirschhorn N. Evolution of the Tobacco Industry Positions on Addiction to Nicotine: A Report Prepared for the Tobacco Free Initiative, World Health Organization . Geneva (Switzerland): World Health Organization, 2009; < http://www .who.int/iris /handle/10665/43988 >; accessed: September 14, 2017.
Hopkins DP, Husten CG, Fielding JE, Rosenquist JN, Westphal LL. Evidence reviews and recommendations on interventions to reduce tobacco use and exposure to environmental tobacco smoke: a summary of selected guidelines. American Journal of Preventive Medicine 2001;20:(2 Suppl):67–87. [ PubMed : 11173216 ]
Huang J, Duan Z, Kwok J, Binns S, Vera LE, Kim Y, Szczypka G, Emery SL. Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the U.S. retail e-cigarette market. Tobacco Control 2018. [ PMC free article : PMC6274629 ] [ PubMed : 29853561 ]
Hughes JR. The hardening hypothesis: is the ability to quit decreasing due to increasing nicotine dependence? A review and commentary. Drug and Alcohol Dependence 2011;117(2-3):111–7. [ PMC free article : PMC3133840 ] [ PubMed : 21411244 ]
Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004;99(1):29–38. [ PubMed : 14678060 ]
Hughes JR, Keely JP, Niaura RS, Ossip-Klein DJ, Richmond RL, Swan GE. Measures of abstinence in clinical trials: issues and recommendations. Nicotine and Tobacco Research 2003;5(1):13–25. [ PubMed : 12745503 ]
Jamal A, Gentzke A, Hu SS, Cullen KA, Apelberg BJ, Homa DM, King BA. Tobacco use among middle and high school students—United States, 2011–2016. Morbidity and Mortality Weekly Report 2017;66(23):597–603. [ PMC free article : PMC5657845 ] [ PubMed : 28617771 ]
Jamal A, King BA, Neff LJ, Whitmill J, Babb SD, Graffunder CM. Current cigarette smoking among adults—United States, 2005–2015. Morbidity and Mortality Weekly Report 2016;65(44):1205–11. [ PubMed : 27832052 ]
Jarvik ME. Further observations on nicotine as the reinforcing agent in smoking. In: Dunn WL Jr, editor. Smoking Behavior: Motives and Incentives . Washington (DC): V. H. Winston and Sons, 1973:33–49.
Joyce GF, Niaura R, Maglione M, Mongoven J, LarsonRotter C, Coan J, Lapin P, Morton S. The effectiveness of covering smoking cessation services for Medicare beneficiaries. Health Services Research 2008;43(6):2106–23. [ PMC free article : PMC2614005 ] [ PubMed : 18783459 ]
Kasza KA, Ambrose BK, Conway KP, Borek N, Taylor K, Goniewicz ML, Cummings KM, Sharma E, Pearson JL, Green VR, et al. Tobacco-product use by adults and youths in the United States in 2013 and 2014. New England Journal of Medicine 2017;376(4):342–53. [ PMC free article : PMC5317035 ] [ PubMed : 28121512 ]
Keller PA, Feltracco A, Bailey LA, Li Z, Niederdeppe J, Baker TB, Fiore MC. Changes in tobacco quitlines in the United States, 2005–2006. Preventing Chronic Disease 2010;7(2):A36. [ PMC free article : PMC2831790 ] [ PubMed : 20158964 ]
King BA, Creamer MR, Harrell M, Kelder S, Norman L, Perry CL. Surgeon General’s reports on tobacco: a continued legacy of unbiased and rigorous synthesis of the scientific evidence. Nicotine and Tobacco Research 2018;20(8):1033–6. [ PMC free article : PMC6023778 ] [ PubMed : 29300946 ]
King BA, Dube SR, Babb SD, McAfee TA. Patient-reported recall of smoking cessation interventions from a health professional. Preventive Medicine 2013;57(5):715–7. [ PMC free article : PMC4572889 ] [ PubMed : 23872172 ]
Kofman M, Dunton K, Senkewicz MB. Implementation of Tobacco Cessation Coverage Under the Affordable Care Act: Understanding How Private Health Insurance Policies Cover Tobacco Cessation Treatments . Washington (DC): Health Policy Institute, Georgetown University, 2012.
Krasnegor NA, editor. The Behavioral Aspects of Smoking. NIDA Research Monograph 26. Rockville (MD): U.S. Department of Health, Education, and Welfare; Public Health Service; Alcohol, Drug Abuse, and Mental Health Administration; National Institute on Drug Abuse; Division of Research, August 1979.
Lee JE, Park EC, Chun SY, Park HK, Kim TH. Sociodemographic and clinical factors contributing to smoking cessation among men: a four-year follow up study of the Korean Health Panel Survey. BMC Public Health 2016;16:908. [ PMC free article : PMC5006525 ] [ PubMed : 27581873 ]
Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD006936. DOI: 10.1002/14651858.CD006936.pub3. [ PubMed : 25726920 ] [ CrossRef ]
Liu X, Li R, Lanza ST, Vasilenko SA, Piper M. Understanding the role of cessation fatigue in the smoking cessation process. Drug and Alcohol Dependence 2013;133(2):548–55. [ PMC free article : PMC4057045 ] [ PubMed : 23954071 ]
Manley MW, Epps RP, Glynn TJ. The clinician’s role in promoting smoking cessation among clinic patients. Medical Clinics of North America 1992;76(2):477–94. [ PubMed : 1548972 ]
McAfee T, Babb S, McNabb S, Fiore MC. Helping smokers quit—opportunities created by the Affordable Care Act. New England Journal of Medicine 2015;372(1):5–7. [ PMC free article : PMC4465216 ] [ PubMed : 25409263 ]
McAfee T, Davis KC, Alexander RL Jr, Pechacek TF, Bunnell R. Effect of the first federally funded U.S. antismoking national media campaign. Lancet 2013;382(9909):2003–11. [ PubMed : 24029166 ]
McAfee T, Sofian NS, Wilson J, Hindmarsh M. The role of tobacco intervention in population-based health care: a case study. American Journal of Preventive Medicine 1998;14:(3 Suppl):46–52. [ PubMed : 9566937 ]
Mermelstein R, Colby SM, Patten C, Prokhorov A, Brown R, Myers M, Adelman W, Hudmon K, McDonald P. Methodological issues in measuring treatment outcome in adolescent smoking cessation studies. Nicotine and Tobacco Research 2002;4(4):395–403. [ PubMed : 12521399 ]
Montalto NJ, Ferry LH, Stanhiser T. Tobacco dependence curricula in undergraduate osteopathic medical education. Journal of the American Osteopathic Association 2004;104(8):317–23. [ PubMed : 15345701 ]
National Academies of Sciences, Engineering, and Medicine. Public Health Consequences of E-Cigarettes . Washington (DC): The National Academies Press, 2018. [ PubMed : 29894118 ]
National Cancer Institute. Those Who Continue to Smoke: Is Achieving Abstinence Harder and Do We Need to Change Our Interventions? Smoking and Tobacco Control Monograph No. 15. Bethesda (MD): U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 2003.
National Cancer Institute. The Role of the Media in Promoting and Reducing Tobacco Use . Smoking and Tobacco Control Monograph No. 19. Bethesda (MD): U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 2008. NIH Publication No. 07-6242.
National Conference of State Legislatures. Marijuana Overview: Legalization, 2016; < http://www .ncsl.org/research /civil-and-criminal-justice /marijuana-over-view.aspx >; accessed: November 5, 2019.
National Institute on Drug Abuse. Research Reports: Tobacco, Nicotine, and E-Cigarettes . Bethesda (MD): National Institutes of Health, National Institute on Drug Abuse, 2018.
North American Quitline Consortium. North American quitlines: a profile of reach and services in 2005 across the U.S. and Canada, 2007; < http://c .ymcdn.com/sites/www .naquitline.org /resource/resmgr/docs /factsheet-survey2007.pdf >; accessed: September 14, 2017.
Oakes W, Chapman S, Borland R, Balmford J, Trotter L. “Bulletproof skeptics in life’s jungle”: which self-exempting beliefs about smoking most predict lack of progression towards quitting? Preventive Medicine 2004;39(4):776–82. [ PubMed : 15351545 ]
Office of the U.S. Surgeon General. Surgeon General’s Advisory on E-Cigarette Use Among Youth , n.d.; < https: //e-cigarettes .surgeongeneral.gov/documents /surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf >; accessed: January 9, 2019.
Orleans CT, Schoenbach VJ, Wagner EH, Quade D, Salmon MA, Pearson DC, Fiedler J, Porter CQ, Kaplan BH. Self-help quit smoking interventions: effects of selfhelp materials, social support instructions, and telephone counseling. Journal of Consulting and Clinical Psychology 1991;59(3):439–48. [ PubMed : 2071729 ]
Ossip-Klein DJ, Giovino GA, Megahed N, Black PM, Emont SL, Stiggins J, Shulman E, Moore L. Effects of a smoker’s hotline: results of a 10-county self-help trial. Journal of Consulting and Clinical Psychology 1991;59(2):325–32. [ PubMed : 2030195 ]
Parascandola M. Tobacco harm reduction and the evolution of nicotine dependence. American Journal of Public Health 2011;101(4):632–41. [ PMC free article : PMC3052352 ] [ PubMed : 21330596 ]
Patton GC, Coffey C, Carlin JB, Sawyer SM, Lynskey M. Reverse gateways? Frequent cannabis use as a predictor of tobacco initiation and nicotine dependence. Addiction 2005;100(10):1518–25. [ PubMed : 16185213 ]
Pfizer. Medication guide: Chantix (varenicline) tablets, February 2019; < http://labeling .pfizer .com/ShowLabeling.aspx?id =557&section=MedGuide >; accessed: July 16, 2019.
Polito JR. Freedom from Nicotine: The Journey Home , 2013; < http://whyquit .com/ffn/index.html >; accessed: September 14, 2017.
Powers CA, Zapka JG, Bognar B, Dube C, Hyder Ferry L, Ferguson KJ, O’Donnell J F, Rigotti N, Conley Thomson C, White M, et al. Evaluation of current tobacco curriculum at 12 U.S. medical schools. Journal of Cancer Education 2004;19(4):212–9. [ PubMed : 15725638 ]
Prochaska JO, DiClemente CC, Velicer WF, Rossi JS. Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychology 1993;12(5):399–405. [ PubMed : 8223364 ]
Proctor RN. Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition . Berkeley (CA): University of California Press, 2011.
Radding B. Pax Juul: the iPhone of e-cigs?, n.d.; < https://www .mensfitness .com/life/gearandtech /pax-juul-iphone-e-cigs >; accessed: August 9, 2018.
Redmond LA, Adsit R, Kobinsky KH, Theobald W, Fiore MC. A decade of experience promoting the clinical treatment of tobacco dependence in Wisconsin. Wisconsin Medical Journal 2010;109(2):71–8. [ PubMed : 20443325 ]
Richmond R, Zwar N, Taylor R, Hunnisett J, Hyslop F. Teaching about tobacco in medical schools: a worldwide study. Drug and Alcohol Review 2009;28(5):484–97. [ PubMed : 19737207 ]
Rothman KJ, Greenland S. Modern Epidemiology . 2nd ed. Philadelphia (PA): Lippincott-Raven, 1998.
Saggio J. What is a Juul? It’s a trend parents need to know about. Florida Today , 2018; < https://www .floridatoday .com/story/news/2018 /02/02/what-juul-its-trend-parents-need-know/1070088001 >; accessed: August 9, 2018.
Schauer GL, Berg CJ, Kegler MC, Donovan DM, Windle M. Differences in tobacco product use among past month adult marijuana users and nonusers: findings from the 2003–2012 National Survey on Drug Use and Health. Nicotine and Tobacco Research 2016;18(3):281–8. [ PubMed : 26009578 ]
Schauer GL, King BA, McAfee TA. Prevalence, correlates, and trends in tobacco use and cessation among current, former, and never adult marijuana users with a history of tobacco use, 2005–2014. Addictive Behaviors 2017;73:165–71. [ PubMed : 28525833 ]
Schlam TR, Baker TB. Interventions for tobacco smoking. Annual Review of Clinical Psychology 2013;9:675–702. [ PMC free article : PMC5844577 ] [ PubMed : 23297788 ]
Schneider NG, Olmstead RE, Franzon MA, Lunell E. The nicotine inhaler: clinical pharmacokinetics and comparison with other nicotine treatments. Clinical Pharmacokinetics 2001;40(9):661–84. [ PubMed : 11605715 ]
Schroeder SA. What to do with a patient who smokes. JAMA: the Journal of the American Medical Association 2005;294(4):482–7. [ PubMed : 16046655 ]
Schroeder SA, Morris CD. Confronting a neglected epidemic: tobacco cessation for persons with mental illnesses and substance abuse problems. Annual Review of Public Health 2010;31:297–314. [ PubMed : 20001818 ]
Scott KA, Mason MJ, Mason JD. I’m not a smoker: constructing protected prototypes for risk behavior. Journal of Business Research 2015;68(10):2198–206.
Shiffman S. Ecological momentary assessment (EMA) in studies of substance use. Psychological Assessment 2009;21(4):486–97. [ PMC free article : PMC2846437 ] [ PubMed : 19947783 ]
Shiffman S, West R, Gilbert D. Recommendation for the assessment of tobacco craving and withdrawal in smoking cessation trials. Nicotine and Tobacco Research 2004;6(4):599–614. [ PubMed : 15370156 ]
Shihadeh A, Eissenberg T. Electronic cigarette effectiveness and abuse liability: predicting and regulating nicotine flux. Nicotine and Tobacco Research 2015;17(2):158–62. [ PMC free article : PMC4837999 ] [ PubMed : 25180079 ]
Siu AL. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine 2015;163(8):622–34. [ PubMed : 26389730 ]
Smith MW, Chen S, Siroka AM, Hamlett-Berry K. Using policy to increase prescribing of smoking cessation medications in the VA healthcare system. Tobacco Control 2010;19(6):507–11. [ PubMed : 20870742 ]
Smokefree .gov . Sign up for SmokefreeTXT, n.d.; < https://smokefree .gov/smokefreetxt >; accessed: August 17, 2017.
Solberg LI, Maxwell PL, Kottke TE, Gepner GJ, Brekke ML. A systematic primary care office-based smoking cessation program. Journal of Family Practice 1990;30(6):647–54. [ PubMed : 2345333 ]
Soule EK, Pomeranz JL, Moorhouse MD, Barnett TE. Multiple tobacco use and increased nicotine dependence among people with disabilities. Disability and Health Journal 2015;8(2):258–63. [ PubMed : 25445017 ]
Squiers L, Brown D, Parvanta S, Dolina S, Kelly B, Dever J, Southwell BG, Sanders A, Augustson E. The SmokefreeTXT (SFTXT) study: web and mobile data collection to evaluate smoking cessation for young adults. JMIR Research Protocols 2016;5(2):e134. [ PMC free article : PMC4940604 ] [ PubMed : 27349898 ]
Squiers LB, Augustson E, Brown D, Kelly B, Southwell B, Dever J, Dolina S, Tzeng J, Parvanta S, Holt S, et al. An experimental comparison of mobile texting programs to help young adults quit smoking. Health Systems 2017;6(1):1–14.
SRNT Subcommittee on Biochemical Verification. Biochemical verification of tobacco use and cessation. Nicotine and Tobacco Research 2002;4(2):149–59. [ PubMed : 12028847 ]
Stead LF, Hartmann-Boyce J, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD002850. DOI: 10.1002/14651858.CD002850.pub3. [ PubMed : 23934971 ] [ CrossRef ]
Strecher VJ, Kreuter M, Den Boer DJ, Kobrin S, Hospers HJ, Skinner CS. The effects of computer-tailored smoking cessation messages in family practice settings. Journal of Family Practice 1994;39(3):262–70. [ PubMed : 8077905 ]
Strecher VJ, Shiffman S, West R. Randomized controlled trial of a web-based computer-tailored smoking cessation program as a supplement to nicotine patch therapy. Addiction 2005;100(5):682–8. [ PubMed : 15847626 ]
Suiters K. Are your kids JUULing at school? 7 on your side investigates, January 31, 2018; < http://wjla .com/features /7-on-your-side/are-your-kids-juuling-at-school-7-on-your-side-investigates >; accessed: August 9, 2018.
Szatkowski L, McNeill A. Diverging trends in smoking behaviors according to mental health status. Nicotine and Tobacco Research 2015;17(3):356–60. [ PMC free article : PMC5479511 ] [ PubMed : 25180078 ]
Taber JM, Klein WM, Ferrer RA, Augustson E, Patrick H. A pilot test of self-affirmations to promote smoking cessation in a national smoking cessation text messaging program. JMIR mHealth uHealth 2016;4(2):e71. [ PMC free article : PMC4917724 ] [ PubMed : 27278108 ]
Teitell B. “Juuling”: The most widespread phenomenon you’ve never heard of. The Boston Globe , November 16, 2017; < https://www .bostonglobe .com/metro/2017/11 /15/where-teenagers-are-high-school-bathrooms-vaping /IJ6xYWWlOTKqsUGTTlw4UO /story.html >; accessed: August 9, 2018.
Torabi MR, Tao R, Jay SJ, Olcott C. A cross-sectional survey on the inclusion of tobacco prevention/cessation, nutrition/diet, and exercise physiology/fitness education in medical school curricula. JAMA: the Journal of the American Medical Association 2011;103(5):400–6. [ PubMed : 21809789 ]
Trinidad DR, Perez-Stable EJ, Messer K, White MM, Pierce JP. Menthol cigarettes and smoking cessation among racial/ethnic groups in the United States. Addiction 2010;105:(Suppl 1):84–94. [ PMC free article : PMC4214376 ] [ PubMed : 21059139 ]
U.S. Department of Health, Education, and Welfare. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service . Washington: U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control, 1964. PHS Publication No. 1103.
U.S. Department of Health, Education, and Welfare. Smoking and Health. A Report of the Surgeon General . Washington: U.S. Department of Health, Education, and Welfare, Office of the Assistant Secretary for Health, Office on Smoking and Health, 1979. DHEW Publication No. (PHS) 79-50066.
U.S. Department of Health and Human Services. The Health Consequences of Smoking: Cancer. A Report of the Surgeon General . Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Office on Smoking and Health, 1982. DHHS Publication No. (PHS) 82-50179.
U.S. Department of Health and Human Services. The Health Consequences of Smoking: Cardiovascular Disease. A Report of the Surgeon General . Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Office on Smoking and Health, 1983. DHHS Publication No. (PHS) 84-50204.
U.S. Department of Health and Human Services. The Health Consequences of Smoking: Chronic Obstructive Lung Disease. A Report of the Surgeon General . Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Office on Smoking and Health, 1984. DHHS Publication No. (PHS) 84-50205.
U.S. Department of Health and Human Services. The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General . Atlanta (GA): U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1988. DHHS Publication No. (CDC) 88-8406.
U.S. Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General . Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1989. DHHS Publication No. (CDC) 89-8411.
U.S. Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General . Rockville (MD): U.S. Department of Health and Human Services, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990. DHHS Publication No. (CDC) 90-8416. [ PubMed : 32255575 ]
U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General . Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004.
U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease—The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General . Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. [ PubMed : 21452462 ]
U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General . Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. [ PubMed : 24455788 ]
U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General . Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health 2016. [ PubMed : 30869850 ]
U.S. Department of Justice. Print corrective statements— exhibit 3: newspaper exemplars, October 2, 2017a; < https://www .justice.gov /opa/press-release /file/1013581/download >; accessed: April 11, 2019.
U.S. Department of Justice. Tobacco companies to begin issuing court-ordered statements in tobacco racketeering suit [press release], November 22, 2017b; < https://www .justice.gov /opa/pr/tobacco-companies-begin-issuing-court-ordered-statements-tobacco-racketeering-suit >; accessed: April 11, 2019.
U.S. Food and Drug Administration. Statement from FDA Commissioner Scott Gottlieb, M.D., on new enforcement actions and a Youth Tobacco Prevention Plan to stop youth use of, and access to, JUUL and other e-cigarettes [press release], April 24, 2018; < https://www .fda.gov/NewsEvents /Newsroom/PressAnnouncements /ucm605432.htm >; accessed: August 9, 2018.
U.S. Food and Drug Administration (FDA). Want to Quit Smoking? FDA-Approved Products Can Help [consumer update], 2017; < https://www .fda.gov/ForConsumers /ConsumerUpdates/ucm198176 .htm >; accessed: August 1, 2018.
U.S. Preventive Services Task Force. Final Update Summary: Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions, September 2015; < https://www .uspreventiveservicestaskforce .org/Page/Document/UpdateSummaryFinal /tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1 >; accessed: May 24, 2017.
Ussher M, Beard E, Abikoye G, Hajek P, West R. Urge to smoke over 52 weeks of abstinence. Psychopharmacology 2013;226(1):83–9. [ PubMed : 23052572 ]
Vidrine JI, Shete S, Cao Y, Greisinger A, Harmonson P, Sharp B, Miles L, Zbikowski SM, Wetter DW. Ask-Advise-Connect: a new approach to smoking treatment delivery in health care settings. JAMA Internal Medicine 2013;173(6):458–64. [ PMC free article : PMC3858085 ] [ PubMed : 23440173 ]
Villanti AC, Mowery PD, Delnevo CD, Niaura RS, Abrams DB, Giovino GA. Changes in the prevalence and correlates of menthol cigarette use in the USA, 2004–2014. Tobacco Control 2016;25:(Suppl 2):ii14–ii20. [ PubMed : 27729565 ]
Vogt F, Hall S, Marteau TM. General practitioners’ and family physicians’ negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review. Addiction 2005;100(10):1423–31. [ PubMed : 16185204 ]
Wang TW, Asman K, Gentzke AS, Cullen KA, Holder-Hayes E, Reyes-Guzman C, Jamal A, Neff L, King BA. Tobacco product use among adults—United States, 2017. Morbidity and Mortality Weekly Report 2018;67(44):1225–32. [ PMC free article : PMC6223953 ] [ PubMed : 30408019 ]
Wang TW, Kenemer B, Tynan MA, Singh T, King B. Consumption of combustible and smokeless tobacco— United States, 2000–2015. Morbidity and Mortality Weekly Report 2016;65(48):1357–63. [ PMC free article : PMC5584068 ] [ PubMed : 27932780 ]
Warner KE, Mendez D. E-cigarettes: comparing the possible risks of increasing smoking initiation with the potential benefits of increasing smoking cessation. Nicotine and Tobacco Research 2019;21(1):41–7. [ PubMed : 29617887 ]
Wells Fargo Securities. Nielsen: Tobacco “All Channel” Data: Marlboro Vol Weak But Share Pressures Ease . Equity Research. San Francisco (CA): Wells Fargo Securities, 2018.
West R, May S, West M, Croghan E, McEwen A. Performance of English stop smoking services in first 10 years: analysis of service monitoring data. BMJ 2013;347:f4921. [ PubMed : 23963106 ]
Wetter DW, McClure JB, de Moor C, Cofta-Gunn L, Cummings S, Cinciripini PM, Gritz ER. Concomitant use of cigarettes and smokeless tobacco: prevalence, correlates, and predictors of tobacco cessation. Preventive Medicine 2002;34(6):638–48. [ PubMed : 12052025 ]
Whittaker R, McRobbie H, Bullen C, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD006611. DOI: 10.1002/14651858.CD006611.pub4. [ PMC free article : PMC6485940 ] [ PubMed : 27060875 ] [ CrossRef ]
Willett JG, Bennett M, Hair EC, Xiao H, Greenberg MS, Harvey E, Cantrell J, Vallone D. Recognition, use and perceptions of JUUL among youth and young adults. Tobacco Control 2018. [ PubMed : 29669749 ]
Zhang L, Malarcher A, Mann N, Campbell K, Davis K, Anderson C, Alexander R, Rodes R. The influence of state-specific quitline numbers on call volume during a national tobacco education campaign promoting 1-800-QUIT-NOW. Nicotine and Tobacco Research 2016;18(8):1780–5. [ PubMed : 27073208 ]
Zhu SH, Lee M, Zhuang YL, Gamst A, Wolfson T. Interventions to increase smoking cessation at the population level: how much progress has been made in the last two decades? Tobacco Control 2012;21(2):110–8. [ PMC free article : PMC3446870 ] [ PubMed : 22345233 ]
Zhu SH, Stretch V, Balabanis M, Rosbrook B, Sadler G, Pierce JP. Telephone counseling for smoking cessation: effects of single-session and multiple-session interventions. Journal of Consulting and Clinical Psychology 1996;64(1):202–11. [ PubMed : 8907100 ]

For reference entries that contain URLs, those URLs were active on the access date presented in the respective reference entry.

Unless otherwise noted in the text, all material appearing in this work is in the public domain and may be reproduced without permission. Citation of the source is appreciated.

Cite this Page United States Public Health Service Office of the Surgeon General; National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Smoking Cessation: A Report of the Surgeon General [Internet]. Washington (DC): US Department of Health and Human Services; 2020. Chapter 1, Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation.
PDF version of this title (9.8M)
Disable Glossary Links

In this Page

Other titles in this collection.

Publications and Reports of the Surgeon General

Related information

PMC PubMed Central citations
PubMed Links to PubMed

Recent Activity

Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation - Smo... Introduction, Conclusions, and the Evolving Landscape of Smoking Cessation - Smoking Cessation

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

Home — Essay Samples — Nursing & Health — Nursing — Argumentative Essay On Smoking Cigarettes

Argumentative Essay on Smoking Cigarettes

Categories: Nursing

About this sample

Words: 507 |

Published: Mar 13, 2024

Words: 507 | Page: 1 | 3 min read

Health effects of smoking, economic implications, impact on non-smokers, the case for regulation, references:.

Centers for Disease Control and Prevention. (2020). Smoking & Tobacco Use. Retrieved from https://www.cdc.gov/tobacco/data_statistics/index.htm

Cite this Essay

Let us write you an essay from scratch

450+ experts on 30 subjects ready to help
Custom essay delivered in as few as 3 hours

Get high-quality help

Dr. Heisenberg

Verified writer

Expert in: Nursing & Health

+ 120 experts online

By clicking “Check Writers’ Offers”, you agree to our terms of service and privacy policy . We’ll occasionally send you promo and account related email

No need to pay just yet!

Related Essays

2 pages / 872 words

1 pages / 599 words

4 pages / 1784 words

4 pages / 2141 words

Remember! This is just a sample.

You can get your custom paper by one of our expert writers.

121 writers online

Still can’t find what you need?

Browse our vast selection of original essay samples, each expertly formatted and styled

Related Essays on Nursing

When driving around Miami, FL there are a copious number of billboards that I see advertising for people to become nurses throughout the city. When doing research, I’ve only come across a couple of news articles, advertising on [...]

Gagnon, K., & Sabus, C. (2015). Professionalism in a Digital Age: Opportunities and Considerations for Using Social Media in Health Care. Physical Therapy, 95(3), 406–414.Nayak, S. G. (2018). Time Management in Nursing -- Hour [...]

Clinical learning experiences hold a paramount role in nursing education, serving as a bridge between theoretical knowledge and practical application. This essay explores the essential role of clinical placements in developing [...]

A Better NHS. (2011). Patient autonomy and choice. Retrieved from 71-77.

Postpartum hemorrhage is a significant risk in the postpartum period, requiring prompt recognition, assessment, prevention, and management. Nursing care plays a pivotal role in ensuring the well-being of women experiencing [...]

In the world of healthcare, professionalism is the cornerstone of nursing practice. It encompasses a set of qualities and behaviors that not only uphold the standards of the profession but also ensure the delivery of safe and [...]

Get Your Personalized Essay in 3 Hours or Less!

We use cookies to personalyze your web-site experience. By continuing we’ll assume you board with our cookie policy .

Instructions Followed To The Letter
Deadlines Met At Every Stage
Unique And Plagiarism Free

Health Effects of Cigarette Smoking

Smoking and death, smoking and increased health risks, smoking and cardiovascular disease, smoking and respiratory disease, smoking and cancer, smoking and other health risks, quitting and reduced risks.

Cigarette smoking harms nearly every organ of the body, causes many diseases, and reduces the health of smokers in general. 1,2

Quitting smoking lowers your risk for smoking-related diseases and can add years to your life. 1,2

Cigarette smoking is the leading cause of preventable death in the United States. 1

Cigarette smoking causes more than 480,000 deaths each year in the United States. This is nearly one in five deaths. 1,2,3
Human immunodeficiency virus (HIV)
Illegal drug use
Alcohol use
Motor vehicle injuries
Firearm-related incidents
More than 10 times as many U.S. citizens have died prematurely from cigarette smoking than have died in all the wars fought by the United States. 1
Smoking causes about 90% (or 9 out of 10) of all lung cancer deaths. 1,2 More women die from lung cancer each year than from breast cancer. 5
Smoking causes about 80% (or 8 out of 10) of all deaths from chronic obstructive pulmonary disease (COPD). 1
Cigarette smoking increases risk for death from all causes in men and women. 1
The risk of dying from cigarette smoking has increased over the last 50 years in the U.S. 1

Smokers are more likely than nonsmokers to develop heart disease, stroke, and lung cancer. 1

For coronary heart disease by 2 to 4 times 1,6
For stroke by 2 to 4 times 1
Of men developing lung cancer by 25 times 1
Of women developing lung cancer by 25.7 times 1
Smoking causes diminished overall health, increased absenteeism from work, and increased health care utilization and cost. 1

Smokers are at greater risk for diseases that affect the heart and blood vessels (cardiovascular disease). 1,2

Smoking causes stroke and coronary heart disease, which are among the leading causes of death in the United States. 1,3
Even people who smoke fewer than five cigarettes a day can have early signs of cardiovascular disease. 1
Smoking damages blood vessels and can make them thicken and grow narrower. This makes your heart beat faster and your blood pressure go up. Clots can also form. 1,2
A clot blocks the blood flow to part of your brain;
A blood vessel in or around your brain bursts. 1,2
Blockages caused by smoking can also reduce blood flow to your legs and skin. 1,2

Smoking can cause lung disease by damaging your airways and the small air sacs (alveoli) found in your lungs. 1,2

Lung diseases caused by smoking include COPD, which includes emphysema and chronic bronchitis. 1,2
Cigarette smoking causes most cases of lung cancer. 1,2
If you have asthma, tobacco smoke can trigger an attack or make an attack worse. 1,2
Smokers are 12 to 13 times more likely to die from COPD than nonsmokers. 1

Smoking can cause cancer almost anywhere in your body: 1,2

Blood (acute myeloid leukemia)
Colon and rectum (colorectal)
Kidney and ureter
Oropharynx (includes parts of the throat, tongue, soft palate, and the tonsils)
Trachea, bronchus, and lung

Smoking also increases the risk of dying from cancer and other diseases in cancer patients and survivors. 1

If nobody smoked, one of every three cancer deaths in the United States would not happen. 1,2

Smoking harms nearly every organ of the body and affects a person’s overall health. 1,2

Preterm (early) delivery
Stillbirth (death of the baby before birth)
Low birth weight
Sudden infant death syndrome (known as SIDS or crib death)
Ectopic pregnancy
Orofacial clefts in infants
Smoking can also affect men’s sperm, which can reduce fertility and also increase risks for birth defects and miscarriage. 2
Women past childbearing years who smoke have weaker bones than women who never smoked. They are also at greater risk for broken bones.
Smoking affects the health of your teeth and gums and can cause tooth loss. 1
Smoking can increase your risk for cataracts (clouding of the eye’s lens that makes it hard for you to see). It can also cause age-related macular degeneration (AMD). AMD is damage to a small spot near the center of the retina, the part of the eye needed for central vision. 1
Smoking is a cause of type 2 diabetes mellitus and can make it harder to control. The risk of developing diabetes is 30–40% higher for active smokers than nonsmokers. 1,2
Smoking causes general adverse effects on the body, including inflammation and decreased immune function. 1
Smoking is a cause of rheumatoid arthritis. 1
Quitting smoking is one of the most important actions people can take to improve their health. This is true regardless of their age or how long they have been smoking. Visit the Benefits of Quitting page for more information about how quitting smoking can improve your health.
U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2017 Apr 20].
U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: What It Means to You . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010 [accessed 2017 Apr 20].
Centers for Disease Control and Prevention. QuickStats: Number of Deaths from 10 Leading Causes—National Vital Statistics System, United States, 2010 . Morbidity and Mortality Weekly Report 2013:62(08);155. [accessed 2017 Apr 20].
Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States . JAMA: Journal of the American Medical Association 2004;291(10):1238–45 [cited 2017 Apr 20].
U.S. Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General . Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001 [accessed 2017 Apr 20].
U.S. Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General . Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1989 [accessed 2017 Apr 20].

To receive email updates about Smoking & Tobacco Use, enter your email address:

Tips From Former Smokers ®
Division of Cancer Prevention and Control
Lung Cancer
National Comprehensive Cancer Control Program
Division of Reproductive Health

Exit Notification / Disclaimer Policy

The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
You will be subject to the destination website's privacy policy when you follow the link.
CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.

Paper writing help
Buy an Essay
Pay for essay
Buy Research Paper
Write My Research Paper
Research Paper Help
Custom Research Paper
Custom Dissertation
Dissertation Help
Buy Dissertation
Dissertation Writer
Write my Dissertation
How it works

How To Write A Smoking Essay That Will Blow Your Classmates out of the Water

Writing a Smoking Essay. Complete Actionable Guide

A smoking essay might not be your first choice, but it is a common enough topic, whether it is assigned by a professor or left to your choice. Today we’ll take you through the paces of creating a compelling piece, share fresh ideas for writing teen smoking essays, and tackle the specifics of the essential parts of any paper, including an introduction and a conclusion.

Why Choose a Smoking Essay?

If you are free to select any topic, why would you open this can of worms? There are several compelling arguments in favor, such as:

A smoking essay can fit any type of writing assignment. You can craft an argumentative essay about smoking, a persuasive piece, or even a narration about someone’s struggle with quitting. It’s a rare case of a one-size-fits-all topic.
There is an endless number of environmental essay topics ideas . From the reasons and history of smoking to health and economic impact, as well as psychological and physiological factors that make quitting so challenging.
A staggering number of reliable sources are available online. You won’t have to dig deep to find medical or economic research, there are thousands of papers published in peer-reviewed journals, ready and waiting for you to use them.

Essential Considerations for Your Essay on Smoking

Whether you are writing a teenage smoking essay or a study of health-related issues, you need to stay objective and avoid including any judgment into your assignment. Even if you are firmly against smoking, do not let emotions direct your writing. You should also keep your language tolerant and free of offensive remarks or generalizations.

The rule of thumb is to keep your piece academic. It is an essay about smoking cigarettes you have to submit to your professor, not a blog post to share with friends.

How to Generate Endless Smoking Essay Topic Ideas

At first, it might seem that every theme has been covered by countless generations of your predecessors. However, there are ways to add a new spin to the dullest of topics. We’ll share a unique approach to generating new ideas and take the teenage smoking essay as an example. To make it fresh and exciting, you can:

Add a historic twist to your topic. For instance, research the teenage smoking statistics through the years and theorize the factors that influence the numbers.
Compare the data across the globe. You can select the best scale for your paper, comparing smoking rates in the neighboring cities, states, or countries.
Look at the question from an unexpected perspective. For instance, research how the adoption of social media influenced smoking or whether music preferences can be related to this habit.

The latter approach on our list will generate endless ideas for writing teen smoking essays. Select the one that fits your interests or is the easiest to research, depending on the time and effort you are willing to put into essay writing .

How To Write An Essay About Smoking Cigarettes

A smoking essay follows the same rules as an academic paper on any other topic. You start with an introduction, fill the body paragraphs with individual points, and wrap up using a conclusion. The filling of your “essay sandwich” will depend on the topic, but we can tell for sure what your opening and closing paragraphs should be like.

Smoking Essay Introduction

Whether you are working on an argumentative essay about smoking or a persuasive paper, your introduction is nothing but a vessel for a thesis statement. It is the core of your essay, and its absence is the first strike against you. Properly constructed thesis sums up your point of view on the economic research topics and lists the critical points you are about to highlight. If you allude to the opposing views in your thesis statement, the professor is sure to add extra points to your grade.

The first sentence is crucial for your essay, as it sets the tone and makes the first impression. Make it surprising, exciting, powerful with facts, statistics, or vivid images, and it will become a hook to lure the reader in deeper.

Round up the introduction with a transition to your first body passage and the point it will make. Otherwise, your essay might seem disjointed and patchy. Alternatively, you can use the first couple of sentences of the body paragraph as a transition.

Smoking Essay Conclusion

Any argumentative and persuasive essay on smoking must include a short conclusion. In the final passage, return to your thesis statement and repeat it in other words, highlighting the points you have made throughout the body paragraphs. You can also add final thoughts or even a personal opinion at the end to round up your assignment.

Think of the conclusion as a mirror reflection of your introduction. Start with a transition from the last body paragraph, follow it with a retelling of your thesis statement, and complete the passage with a powerful parting thought that will stay with the reader. After all, everyone remembers the first and last points most vividly, and your opening and closing sentences are likely to have a significant influence on the final grade.

Bonus Tips on How to Write a Persuasive Essay About Smoking

With the most challenging parts of the smoking essay out of the way, here are a couple of parting tips to ensure your paper gets the highest grade possible:

Do not rely on samples you find online to guide your writing. You can never tell what grade a random essay about smoking cigarettes received. Unless you use winning submissions from essay competitions, you might copy faulty techniques and data into your paper and get a reduced grade.
Do not forget to include references after the conclusion and cite the sources throughout the paper. Otherwise, you might get accused of academic dishonesty and ruin your academic record. Ask your professor about the appropriate citation style if you are not sure whether you should use APA, MLA, or Chicago.
Do not submit your smoking essay without editing and proofreading first. The best thing you can do is leave the piece alone for a day or two and come back to it with fresh eyes and mind to check for redundancies, illogical argumentation, and irrelevant examples. Professional editing software, such as Grammarly, will help with most typos and glaring errors. Still, it is up to you to go through the paper a couple of times before submission to ensure it is as close to perfection as it can get.
Do not be shy about getting help with writing smoking essays if you are out of time. Professional writers can take over any step of the writing process, from generating ideas to the final round of proofreading. Contact our agents or skip straight to the order form if you need our help to complete this assignment.

We hope our advice and ideas for writing teen smoking essays help you get out of the slump and produce a flawless piece of writing worthy of an A. For extra assistance with choosing the topic, outlining, writing, and editing, reach out to our support managers .

Save your essays here so you can locate them quickly!
Tobacco Smoking
Drug Addiction
Heart Attacks
Coronary Heart Disease

SMOKING KILLS 4 Pages 987 Words

Smoking is bad for your body and your overall health. There are many side affects that can hurt and even kill your body. It also can harm your lungs and make it hard for you to breathe. When you look at the statistics I don't understand why people do smoke. Cigarette smoking is the most important preventable cause of premature death in the United States. It accounts for about 430,700 of the more than 2 million annual deaths. Cigarette manufacturers spend millions of dollars every year to convince you and your children that smoking will make you exciting, athletic, important, sophisticated, and sexually attractive. They carefully avoid mentioning the intense addictive qualities of nicotine and the well-documented, serious health risks involved. Quitting smoking is the best preventive medicine: Experts estimate that stopping smoking is about 10 times more cost-effective at saving lives than even the best medical screening tests. The benefits are enormous. Your heart, lungs, and blood vessels have an amazing capacity to heal themselves when given the chance. When you stop smoking, your body starts repairing itself almost immediately. And with proper nutrition and activity, you can usually regain normal lung and heart functioning within a few years, regardless of how long you've been smoking. The risk of heart attack, stroke, and cancer starts dropping immediately. Cigarette smoke contains over 4,000 chemicals, including 43 known cancer-causing (carcinogenic) compounds and 400 other toxins. These include nicotine, tar, and carbon monoxide, as well as formaldehyde, ammonia, hydrogen cyanide, arsenic, and DDT. Most of the chemicals inhaled in cigarette smoke stay in the lungs. The more you inhale, the better it feels-and the greater the damage to your lungs. As a cigarette is smoked, the amount of tar inhaled into the lungs increases, and the last puff contains more than twice as much tar as the first puff. Carbon monoxi ...

Continue reading this essay Continue reading

Page 1 of 4

More Essays:

Share full article

This Is a Very Weird Moment in the History of Drug Laws

The war on drugs failed, but decriminalization is facing its own backlash. what’s next.

[MUSIC PLAYING]

From New York Times Opinion, this is “The Ezra Klein Show.”

In 2020, voters in Oregon passed a ballot measure, a drug reform policy, that was beyond what I ever thought would pass in any state in America.

Overnight, Oregon became the first state in the country to decriminalize most street drugs.

Even drugs like cocaine, heroin, meth, and oxycodone.

It’s a sea change. Measure 110, which was passed by 58 percent of Oregon voters, treats active drug users as potential patients rather than criminals.

I’ve been involved in drug policy reform for a long time. I got into it in high school. And this was not a politics that seemed possible back then. In that era, the idea that you would have a state decriminalize heroin possession, I mean, it was unthinkable. But in the coming decades, there would be a real turn on the war on drugs — the overpolicing, the mass incarceration, the racism, the broken families. It was not achieving, as far as anybody could tell, anybody’s policy goals.

So we began to move in this other direction. Oregon was at the vanguard of this, but it wasn’t alone. In Washington state, you saw the Supreme Court overturn the law that had made a lot of drug possessions and felonies. In a bunch of different cities, you had these very liberal district attorneys who instead of running on tough on crime platforms were running against overpolicing, against mass incarceration.

Something that had really never been tried before in America was all of a sudden being tried. We were moving towards a radically different equilibrium than anybody had imagined even just a few years before on drugs. I mean, you could walk down the streets — you can right now in many states — and buy all kinds of cannabis products from shops. It was, again, unthinkable.

But this politics and these policies are not working out the way people had hoped. Chesa Boudin, who was the district attorney in San Francisco, one of these very liberal set of reformers, he was recalled. Legislation was passed rebuilding an enforcement structure around drugs in Washington state. There are a lot of concerns and, I think, quite bright ones about how cannabis legalization and particularly cannabis commercialization is working out in a bunch of places.

And in Oregon, Measure 110 was gutted. The results of it had not been what many of the advocates had hoped for. Drug policy feels very unsettled to me right now. The war on drugs was a failure, often a cruel one. The war on the war on drugs has not been the success its advocates had hoped. So what comes next?

Keith Humphreys is a professor at Stanford University who specializes in addiction and drug policy. He’s advised the White House, California, the UK. I always find that he balances compassion and rigor unusually well. So I wanted to have him walk me through what he has seen and where he’s landed. As always, my email for guest suggestions, for reflections, [email protected].

Keith Humphreys, welcome to the show.

Thanks, Ezra. Good to talk to you.

There’s a tendency to just use this term “drugs.” And that tendency just belies a huge amount of variation, I think, in how people think about different drugs, how they think about opioids, how they think about stimulants, how they think about psychedelics, how they think about cannabis, alcohol, caffeine. Is this a useful term?

So “drug” is an incredibly vague term that covers an enormous number of drugs that have very different properties. The biggest one, I think, is the capacity to instill addiction. People don’t get addicted to LSD, for example. But they do get addicted to heroin. That’s really important. They do get addicted to nicotine. That’s really important. So you would think about those drugs differently, the ones that have the ability to generate an illness with obsessive compulsion to use in the face of destructive consequences over and over and over again. Those belong in their own class, I think.

The second thing is that we should stop pretending that legal and illegal drugs are so different for lots of reasons. We could learn much more about what to do with illegal drugs if we looked at legal drugs. When I talk to policymakers, they say, well, I know what I don’t want. And that’s a carceral, racist war on drugs. I say, OK, I’m glad that option is off the table. That, of course, leaves millions and millions of other options to choose from.

And how some people have framed that is there’s really only two choices here. You can have that, that horrible thing. Or you can throw the switch the other way — tolerance, acceptance, public sale. And that’s going to be better.

And the problem with that argument, even before we get into what happened in places like Oregon, is the number one drug that kills people on the planet is cigarettes. The number one drug associated with arrests, violence, and incarceration is alcohol. Those drugs are legal. It’s not that drugs suddenly become easy to deal with once they’re legal.

You get to pick the set of problems you have, as our mutual friend Mark Kleiman used to say. But you don’t get to get rid of those problems. So people are right to identify substantial costs to prohibition of drugs or for that matter of everything. But that is different than saying there is some other framework that doesn’t also include pretty substantial costs.

So this major drug policy reform went into effect in Oregon in 2021, Measure 110. It passes. What happens next?

Part of what happens is exactly what the reformers hoped would happen, which is that there’s a dramatic drop in arrests — arrests for drug possession and arrests for drug dealing. So they say, wow, that’s a victory. On the other hand, some of the other aspects of it didn’t work out the way people planned.

So there was a system that they thought would encourage people to enter treatment in replacement of criminal penalties. You’d be written a ticket, let’s say, if you were using fentanyl on a park bench. And it said there’s $100 fine for doing this, but you don’t have to pay the fine. All you have to do is call this toll free number, and you can get a health assessment and a potential referral to treatment. Well, it turned out that over 95 percent of the people got those tickets simply threw them away, which, keeping with the spirit of the law, there was no consequence for doing that. Hardly anybody called. The new body they set up to distribute the new funds had very serious management problems because the people — they may have been terrific human beings, but they weren’t actually experienced in how do you run a government bureaucracy.

So there was no real improvement in the availability of treatment, no real improvement in the number of people interested in seeking it. And those things may well have contributed to Oregon having a very high overdose rate. So currently going up about 40 percent per year, 4-0. Of course, some of that is due to fentanyl, which is raising — I’m here in California. Our rate’s up 5 percent, but it’s certainly not up 40 percent.

And the last thing is the intangible. And I say this as someone who goes to Oregon a lot and talks to people there almost every week, which is just the change in neighborhoods was really palpable of what it was like to go out in the street or try to go to a park, how much visible drug use you saw, how much disorder connected to it. And this was accentuated even further by the pandemic. There were fewer people on the street who had the choice. So the experience became more frightening as people were perhaps outnumbered in their neighborhood by people who had clearly visible problems were using drugs. And that generated significant and, I think, understandable upset as to how things were going in Oregon.

So not everybody agrees that Measure 110 was a failure, certainly not as a policy. I mean, it definitely failed politically. The Drug Policy Alliance says that it failed because of disinformation because there was a concerted effort to undermine it. And they cite data from the Oregon Health Authority saying that, look, health needs screenings increased by almost 300 percent. Substance use disorder treatment increased by 143 percent. Is there some argument to this that we’re looking at the wrong measures and, judged according to its goals, 110 was actually kind of working?

If what you care about the most was a drop in drug arrests and involvement of people who use drugs and deal drugs in the criminal justice system, then it was a success clearly because there was very little contact anymore between law enforcement and people who sell and deal drugs. But on the health side, no, I don’t think that. And those statistics on treatment I believe count a lot of one time consultations. I think what most people, particularly people who love someone who has an addiction, are looking for is evidence on people getting better, people getting into recovery, not just at some point having some transitory contact with the system.

There’s another argument that’s made in the Drug Policy Alliance document and other things I’ve seen and that has occurred to me, too, because when I think about Oregon, when I think about San Francisco, when I think about Washington State, I mean, you’re talking about places with very broken housing markets. We’ll talk I’m sure more about the Tenderloin.

But the Tenderloin is dystopic in the way the Tenderloin is dystopic because it is a giant homeless encampment. And that was true well before the current wave of drug policy liberalization. And so one argument here is that the drug system is being blamed for policymakers’ inability to solve these other problems. Is there something to that?

There’s an intense argument out here in the Bay Area between people who say, look, the homeless crisis is just a side effect of addiction. And people say, look, the addiction crisis is just a side effect of homelessness. And I would say they’re both wrong in that, even within my personal group of acquaintances, I know people who lost their home because of an addiction. And it’s not that the housing market discharged them, they had an empty property. But they were out on the streets. And then there are people who lost their housing and then were living next to drug markets on the streets and developed an addiction there.

So I don’t think we can separate that Gordian knot. And I don’t know if in policy terms we have to. I mean, I think we should be able to pursue policies that increase the access to housing and still work on policies that reduce the damage from addiction.

So to go back to Oregon and one of the theories that was operating there was that we’re going to move more money into treatment. We’re going to make it easier and safer in the sense that you will not be arrested for seeking treatment. We’re going to make it easier and safer for you to seek treatment. We’re going to make it cheap to seek treatment. Why didn’t more people seek treatment?

That theory reflects a misunderstanding about the nature of addiction, which is that it is like, say, chronic pain or depression, conditions that feel lousy for the person who has them all day long, and they will do anything to get rid of them. Drug addiction is not like that. It has many painful experiences. It destroys people’s lives.

But drug use feels in the short term incredibly good. That is why people do it. They’re getting intense reward. So they are ambivalent about giving that up in a way no one with chronic pain is ambivalent about giving up chronic pain and no one with depression is ambivalent about giving up depression.

The other point about it is a huge number of the problems from drug use and addiction fall on other people rather than the person concerned. And so people like me who work in this field, we get calls and calls and calls from mothers, fathers, brothers, sisters, children concerned about their loved ones. But it’s very rare we get a call from somebody concerned about their own use.

Take the law out of it and look at a drug that is legal and widely accepted. Studies of people who seek treatment for an alcohol problem, slightly over 9 in 10 of those people say they were pressured to come. And the pressure might be family pressure, mom and dad said or my spouse said, this keeps up, I’m moving out. The boss said, one more day drunk at work, and you’re fired. Doctor said, you keep doing this, you will be dead in six months. It could be this is your fourth or fifth arrest for drunk driving, and your lawyer says, you better get into treatment because the judge otherwise might throw you in the penitentiary. That is overwhelmingly the situation of people seeking treatment — pressure from outside.

So let’s just remove all pressure. No legal pressure, no disapproval. Then people will spontaneously say, OK, I really want to make a change, and I’ll come in. Look, those of us who do this for a living, we pray for patients like that. It’s great when they come in, but that is just a very rare person.

Let me ask about this from the other direction, which is maybe this all just wasn’t nearly liberal enough because one of the arguments made — and I do think there’s evidence behind it — is people are getting stuff they don’t know. And the reason people die from fentanyl laced heroin or simply fentanyl that they thought was heroin is because they don’t have a source they can trust. Part of the difficulty here is, yes, people end up addicted. We don’t have really good treatments for addiction that we can come back to whether you think that is a true claim.

And then we also make it very difficult for people and dangerous for people to get what they need to avoid withdrawal to keep feeling normal. And if we made that easier on them, if we made it so they didn’t have to go to a place like the Tenderloin and instead get something safe, they would not die from overdose. They would not die from fentanyl laced heroin. Is there validity to that?

Yeah, well, certainly using fentanyl in an illicit market is extraordinarily dangerous. And my colleagues and I are trying to figure out the death rate per year of a regular user. It might be as high as 5 percent. So that is an extraordinarily dangerous thing to do.

And the arguments you’re making have been influential in this region to the point that if you go up slightly even further in the Pacific Northwest into Canada and British Columbia, they’ve gone so far to say it’s the government’s job to supply these drugs because prohibition makes things more dangerous, so we have a positive obligation to do this. But the problem with that reasoning is we did flood communities with legally made, consistent quality, clearly labeled opioids for years. And the net effect was millions of people getting addicted and hundreds of thousands of people dying.

That’s, in fact, how we got here. I think everyone knows what OxyContin is, all the other opioids that were really pushed out there. So it’s just really hard to sustain that argument that at a population level, huge access to addictive drugs is not going to cause a lot of addiction and overdose as long as they’re clearly labeled and of consistent quality. If that were true, we would never had an opioid crisis.

So Measure 110 passes in 2020. It goes into effect in 2021. What happens to it in 2023?

At that point, overdoses were way up. And popular sentiment has shifted pretty dramatically. I think quite a few people felt burned. They hadn’t gotten what they’d been promised. And that included people who, for example, had relatives who were addicted who they assume would be getting into treatment and recovery and then weren’t able to get services.

Neighborhoods are decaying. Polling showed that about two thirds of the Oregon population wanted Measure 110 repealed in part or in whole. And interestingly, those sentiments were even stronger among Black and Hispanic Oregon residents.

In response to all this, both Houses by very large margins replaced Measure 110 with a different approach to drug policy. It restored the ability to impose criminal penalties, to use those penalties particularly to leverage people to change their behavior — for example, by restoring drug courts and other kinds of diversion and monitoring programs. It is definitely not correct to say they reinstated the war on drugs because, it has to be remembered, Oregon never really had a war on drugs policy. They were the first state in the nation to decriminalize marijuana over 50 years ago, in fact. They decriminalized marijuana. They had a very low rate of putting nonviolent criminals into prisons.

So it was more a restoration of that progressive, liberty loving approach that they’d had before but supplemented with a lot more funding for treatment, which is something they’ve had a lot of problems standing up for years, which had nothing to do with Measure 110. The treatment system was in very bad shape before Measure 110. And it still is.

If you’ve been around drug policy conversations for a long time, you’ll have heard a lot, I have heard a lot, about Portugal. And Portugal is a place where they decriminalized drugs. And it has been a much more sustainable, solid policy. So what is different about Portugal?

Portugal is different in policy and different in culture. So they definitely don’t throw people in prison, and it’s decriminalized. But they do have what are called dissuasion commissions that do assessments of people, say, who arrested in the street for using drugs. And you have to show up to this assessment. And they can push and nudge people to seek care.

And they can also apply penalties if they want to. They can say, you’re a cab driver. You’ve been caught using cocaine. And we’re going to take your cab license away until you seek treatment and stop using cocaine. Things like that. It is not a war on drugs approach, but it is a push in the policy. And that has never been taken on seriously by American advocates who cite Portugal.

Portugal also has a universal health care. We do not have that. We are the only developed Western country that doesn’t have that. So that makes it easier to get help irrespective of what the laws are. And Portugal had at least at the time of their decriminalization a very nice network of treatment services and harm reduction services for people. And all that together worked in the policy mix.

The other point is the culture of Portugal is much more family oriented. It’s much more communitarian than American general and certainly much more true than our freedom loving Libertarian Pacific Coast. If you spend time in Lisbon, you have a common experience of running into people and say, where are you born? And they’ll say, well, Lisbon. And where were your parents born? Lisbon. And they still live in my neighborhood. And my grandparents live in my neighborhood, too. You never hear this in San Francisco or Portland. Everybody is from somewhere else. And many people actually moved to the West to get away from everybody else, to get away from social constraints. I want to be my own person. Well, Portugal is the opposite of that.

So there’s a lot of constraint on behavior. It’s loving constraint, but it is constraint, those boundaries around people’s behavior that don’t exist out in the West with the exception of recent immigrant communities, which, by the way, have very low rates of drug problems.

This is something that I always think people underestimate at least about San Francisco, which is one of these cities under the best, which is that it is a culture of enormous tolerance. And that is a lot of what makes San Francisco remarkable, what has made it a home for L.G.B.T.Q. people when that was a very rare thing to be, what has made it open to all these weird ideas from computer scientists and strange nerds who came around with their thoughts about AI and their thoughts about visual operating systems.

And people don’t like necessarily the dark side of this open, tolerant, nonjudgmental way of looking at the world. There’s a bit of a divided soul, a difficulty judging, a discomfort with paternalism, and a kind of optimism that if you let subcultures have their freedom and grapple their way forward, they’ll find their way to an equilibrium and that we should be very, very, very skeptical of heavy handed particularly law enforcement as a way of changing culture.

That is a very nice description of the city we both love. And we’d be much poorer without San Francisco’s embrace of individual freedom and all the great things that it gives, which you just articulated. To me, the resolution here is taking addiction seriously as a problem.

So if you look at somebody who is using methamphetamine five times a day, you could say, well, that is really an expression of their individual freedom. I need to respect that. But if you recognize the likelihood that they are not particularly free because they are addicted, the inconsistency disappears. And so I feel personally no contradiction between saying the state should intervene with pressure — for example, mandating people into treatment. For me, that doesn’t conflict with individual freedom at all. So when I talked to somebody who said, look, you need to just let people do what they want, I say, look. I volunteer in the Tenderloin. And I carry naloxone, the overdose rescue medication, with me. If someone were in front of me in overdose and dying, should I administer naloxone even though the person can’t consent, they’re unconscious?

And I’ve never had anyone say, you’re right. You should just respect their right to die. They say, well, no, of course, you should do that, conceding the principle that there are times that the thing we can do the most to help other people is take care of them when they were not in a fit state to take care of themselves.

Is that a straw man, though? I can’t really think of people at least that I have heard arguing that somebody under the throes of heroin addiction is free and is choosing the life they live, that they’re likely to be happy with the world they now exist in.

One of the really striking things about this new rhetoric about drug policy out here is how rarely addiction is even mentioned. The fact that there’s so much focus on drug overdose, which is, of course, terrible, but that is treated as the only index and not addiction reflects a viewpoint that that’s not either an important thing or not that real a thing. Because if it were, you would note that in the heyday of wild opioid prescribing, there were fewer overdoses, but there were far more people who were addicted to those substances. And that made their lives dramatically worse.

I also see the lack of attention to addiction in the investment in harm reduction without the idea of using it as a springboard into treatment, which to me is a very novel idea that’s only become more powerful in the last couple of years where people feel like that in itself is the goal versus trying to eliminate addiction and get somebody into recovery.

So this is complicated, I think, because there’s this interaction in this period between what you might call elite and mass drug culture. In this period, you have the rise of a lot of super popular podcasters like Joe Rogan and Tim Ferriss, who are very open about their psychedelic use. You have Michael Pollan’s great book on psychedelics, “How to Change Your Mind.” I do a bunch of podcasts about psychedelics. You have a book by Carl Hart, who’s a well-known drug researcher at Columbia, called “Drug Use for Grownups” where he talks openly about using heroin to relax at the end of the day. Ketamine use rises in a very public way.

And so you have this change in drug culture among elites. It becomes much more acceptable to talk about how you use drugs to improve your life that I think also makes it look hypocritical to have a punitive approach not just legally but culturally towards other kinds of drug use. Do you think there’s something to that?

Yeah. I’ve seen that very much, too. And people with a platform, they’ve got a hearing. One of the most important things to understand about Measure 110, for example, is it passed easily. It was not that controversial as people thought it would be. And that elite change, I think, was part of the dynamic.

And definitely, you could see that in psychedelics in Oregon, which, as you know, has set up an entire system to administer psychedelics as a healing force. At least that’s the theory. These are transformative medicines often, by the way, in advance of evidence. But put that aside for a minute. And that is a remarkable change.

I think the criticism you could make of people who are well off and well resourced and have a lot of social capital and have access to treatment and health care whenever they need it is that they could be overgeneralizing what it’s like to use drugs in that situation versus the situation most people find themselves in with a lot less resources and a lot fewer things to catch them if they develop a problem. Now, some would say, well, the real problem is the law, and it’s the punishment you get and all that. And that can absolutely ruin people’s lives. There’s no question to that.

But there’s also quite a few people whose lives are ruined by drugs, including cannabis. There’s some people whose lives have been ruined by psychedelics and certainly people’s lives ruined by cocaine and fentanyl and so on. You don’t think about that much maybe when you are in a really comfy, well-resourced environment. But the average person who lives in a more typical environment does think about it, does have to worry about it. And that gives them a different understanding of what drugs are, how risky they are, and what they want their government to do about them.

That all makes sense to me. But something else I would say was here was that I would have described the consensus for a very long time as drug use is bad, and policing is good. And to some degree, by the time of 110 and some other reforms we were seeing in other states, I think that there was — and you can tell me if this tracks for you — a belief that drug use is somewhere between neutral and good depending on the drug, and policing is bad.

Yeah. There’s no way to separate what happened in Oregon from the murder of George Floyd and from Black Lives Matter. I mean, the protests against police were as intense in Oregon as anywhere they were in the United States and indeed throughout the region and a lot of concern — and it’s got to be said — a lot of justifiable concern about racism and policing. And a huge portion of that was focused on drug enforcement. And that flip was clearly part of why the bill passed.

In terms of drug use, I think there’s a split. I mean, so there are people who accept it’s a health matter. So let’s move to that part of the population, some of whom will say, it’s not a good idea, but we should add health services, and I certainly wouldn’t punish anybody for it, to people would say, no, it is good. In fact, it is actively good. Drug use is good. Drug use should be accepted and maybe even promoted or celebrated. And the debate has been, I think, between those two strands, whereas in the ‘80s, it was more between “drugs are bad — period” and “they should be legal even if they’re good or bad.”

You’ve written about billboards that I used to see and always thought were somewhat strange around fentanyl use and showing happy people — and these were in San Francisco — showing happy people and suggesting if you’re going to use this stuff, use it with friends. Use it around others. Make sure you’re not doing it alone.

One way of looking at them was as a destigmatization of this. It’s totally fine. Just be safe. And another way of looking at it was a total last gasp, but we don’t know what to do. We’re going to try this approach to everything else is failing. Maybe if we completely turn around our approach and just try to change the social dynamics in which people use, that might have an effect on the margin.

So several things there you’re saying, I think they’re important. One is, absolutely. In the face of all this death and all this suffering, we’re all desperate for solutions. And I think it is good that we are thinking in very fundamental ways about what the solutions are. That should be the case when you have this much suffering.

I think it is not irrelevant that these changes have unfolded during a pandemic where, let’s face it, we all went a little crazy. It was very stressful. It was emotional. Many policy debates took on a very personal cast. And we did rock between different extremes in our politics.

With the billboards — and just to describe these billboards, what to me is interesting about them is that the public health department signed off on these. And if they had been promoting beer, they would’ve been outraged by them because they would’ve said, well, you’re making it look like this is something young, attractive, successful people do. And it’s a lot of fun. And you’re understanding all the risk. And you’re going to be tempting kids. You’re basically giving people really bad information. But it wasn’t alcohol. It was fentanyl.

And so I guess they felt it was reasonable on the idea that this will destigmatize. And then people will be comfortable talking about it and using fentanyl together. And they would show people in the apartment having a nice party. Then they could take care of each other in the event of an overdose. It would be a social event, and then you could be there. To me, it’s an extraordinary chain of reasoning. But that’s where San Francisco got in 2021.

I lived in San Francisco during this period. It also had a highly liberalizing attitude on drugs. It had significant open air drug markets, particularly in the Tenderloin.

But what I always saw as the core thing that was infuriating people because I lived in places like D.C. that had a much higher murder rate but where crime was much less of an angry political issue was a feeling that the government was tolerating disorder, that it wasn’t fighting it and failing or fighting it and failing to triumph over what’s a very hard problem, but that the government was allowing it, that they were allowing these open air drug markets, that they were allowing people to shoot up on the street, and that it turned out the politics of permitting disorder were really, really, really bad.

Yes, they are. And I volunteer in the Tenderloin. So I’ve spent a lot of time in those neighborhoods and definitely pick up that sense. And, say, for a number of people would express it in an even harsher way, which is the government is tolerating it where I live in a way they would never tolerate it in a wealthier neighborhood. That could be coupled also with a sense of some of those people in the wealthier neighborhoods say this should be tolerated, but they’re not having to tolerate it. I am. And that generates understandable anger.

And this has had an interesting racial dimension in my observation of it is that a lot of this tolerance has been pushed in the name of racial justice often by white college educated progressives but is unpopular with many, many people of color who live in low income neighborhoods because they’re paying the cost of it while it’s being advocated for for people who they don’t even know who live in neighborhoods that don’t have these kinds of problems.

I was reading recently a lawsuit filed by residents of the Tenderloin against San Francisco. And it was saying in a way that is illegal and unconstitutional, it was alleging that San Francisco — and everybody knows this to be true — was not enforcing laws in the Tenderloin the way it was in other parts of the city, that it had settled on a containment strategy in the Tenderloin. And the Tenderloin is really rough for people who have not walked around there. I mean, the disorder, the despair, the difficulty’s incredibly visible. And one of the things that was noted in the lawsuit was that the Tenderloin has a much higher ratio of children than most parts of San Francisco. It has a lot of immigrant families, a lot of poor families. And so this is being tolerated where really a lot of kids were.

And the argument was that this was not allowed where richer people lived in San Francisco, and it was where these poorer people lived. And even knowing that, it was striking to see it laid out and to see these experiences of people who were living amidst it laid out and their fury that containment was being done on their backs.

Why are there hundreds of dealers standing on street corners in the Tenderloin and in the south of Market? They are not there to service the neighborhood. Because if you live in a neighborhood and your dealer lives in the neighborhood, your dealer doesn’t have to stand on a corner. You know each other. You can text. You can just stop by and make your transactions.

Open air markets are there to service strangers. They’re so that buyers and sellers can find each other really fast. And in an open air market, it’s serving people who don’t live in the neighborhood. There’s no reason there’d be that many dealers. The Tenderloin doesn’t need that many dealers to pay for its own drug use.

So it’s a legitimate gripe if you live in a neighborhood and you’re trying to raise a family in a neighborhood that is taken over by an open air market to say, we’re taking all the harms of all the drug use of the other neighborhoods where they don’t allow open air dealing. But people know they can just drive from there to here pick up their drugs and then go off about their way. And that’s unfair. And so I sympathize with the residents of the Tenderloin who are raising that very legitimate gripe about not getting equal protection under the law.

One question I’ve had about all this is how much of it is a set of policies that might’ve worked or certainly worked better than they did, but fentanyl rolled a grenade underneath this? I mean, a lot of this thinking was happening years before fentanyl just completely invaded America.

The emergence and dominance of powerful synthetic drugs like fentanyl among the opioids or super strong methamphetamine that is now a larger share of the market than cocaine has, I think, undermined basic assumptions about drug policy across the world. When a kind of person who might come into, say, a methadone clinic addicted to heroin, their heroin use might be once a day or maybe twice a day, including people who were holding jobs, people who still were in touch with their families. Not that life was going well, but there was some level of manageability. We now have people with fentanyl using 10, 20, 30 times a day. Their entire existence is — because fentanyl has a very short cycle of action.

So you wake up. You’re in withdrawal. Withdrawal is incredibly unpleasant. You may smoke fentanyl, smoke, smoke, smoke. Maybe it takes 10 minutes, 20 minutes, 30 minutes. Your withdrawal finally stops. You smoke some more till you get high. You fall asleep. You wake up, and you’re in withdrawal. And you’re just really stuck like that.

And I see people like that. I mean, I’m very optimistic about the potential of recovery for addiction. Those are what I’ve seen. And those are also my values. I try to approach everybody that way.

And I also sometimes am frightened that it’s just much, much harder to help people in this state when their life is that consumed by drugs even relative to how consumed their lives were by drugs like heroin and OxyContin. It’s really pretty frightening. And we are getting it first. The United States and Canada too are being exposed to these drugs.

It’s interesting to note in Europe, they’re just starting to get these drugs. And whether they’ll keep with their same policy mix is a really interesting question. It isn’t entirely sure. I have a colleague who says fentanyl is like an antibiotic resistant infection. The stuff we always done that used to work doesn’t work anymore. And that’s terrifying.

How good now is our best gold standard addiction treatment?

So this varies a lot by drug. I’m going to start with the bad news first, which is the stimulants. So the biggest disappointment of my career is about cocaine and methamphetamine. I started my career in the late 1980s. And the care that people got for those drugs then is almost the same as what they get now. There’s been very little progress.

Billions have been spent. Brilliant people have tried to develop, for example, pharmacological treatments for them. Nothing has panned out yet. Most of the behavioral treatments don’t work. We have one thing that seems to work, which is contingency management, a particular way of structuring and giving rewards to help people make changes in their behavior. But we’ve had that for a very long time. So the news there is kind of disappointing.

For alcohol, funnily enough, one of the best things we have has been around forever, which is Alcoholics Anonymous. And for a long time, people in my field looked down on it as too folky and not medical enough. And yet there’s now tremendous evidence that myself and some colleagues assembled in what’s called a Cochrane Collaboration showing that does work, that people do, in fact, as well or better in Alcoholics Anonymous as they do coming to see people like myself.

There’s also some medications available. Acamprosate is one. Naltrexone is another. Some people benefit from those.

On the opioids, we have multiple approved FDA medications. Methadone has been around a very long time. It’s a substitute medication. It is effective for many people. Buprenorphine is another substitute medication, slightly different pharmacologically, but also effective for a great many people. And we have naltrexone, which is it works differently. It’s a blocking agent. And there are people who do very well on that.

So those things are all good. That’s considered the front line. You offer people medication first. And people also can benefit from other kinds of things — therapies and from residential care. And if somebody is out on the street with an addiction, it’s not believable that they are going to check in once a week for an hour with a therapist because their lives aren’t that organized. They usually need a safe substance free environment in which to stay. And those are often in short supply. So we sometimes don’t have success there not because we don’t know what to do, but because we haven’t allocated the resources to do it.

But how good are any of these? I mean, let’s zoom in on alcohol for a minute. I’ve known a lot of people — people I’ve loved — who have had very severe alcohol addictions. And you can’t be near that and not realize how differently different drugs act on different people. If I am drinking, just at some point, my body is like, that’s good. We’re done.

And there are people I know who they have burnt their life down around them. And they’ve been in and out of residential treatment. They’ve gone to A.A. Some people recover. Often they really don’t. How likely is it if you go into A.A. or some of these other things that you’ll recover?

People who seek for alcohol treatment or Alcoholics Anonymous can fall into three bins. If you look at them about 6 or 12 months later, somewhere between 40 percent, 50 percent are dramatically better off. Their lives are dramatically better. And that could be the completely abstinent, or they’re much more abstinent, but their lives are dramatically better.

Then there’s another group of people who seem to be somewhat better. That might be 20 percent, 25 percent. They’re still having significant problems. But maybe they make some things like, at least I’m not drinking and driving at the same time, or at least my spouse and I are making some progress in our marital communication. And then the remaining people unfortunately look exactly the same as the day they came into treatment. They either made no progress, or they made some slight progress and then relapsed.

The perception that we have of it tends to be driven by that last group. That’s because when people get better, they disappear into the woodwork. So when I worked in the White House, I used to think when I walked by somebody getting out of the metro who’s actively using drugs or alcohol, I’m very aware. That’s so visible to me.

And yet I know every day people walk by me in suits or in recovery, and I don’t notice them at all. Just looks like another Washington lawyer or civil servant or politician. So the cognitive effects of people who are doing the worst or the most vivid give us, I think, a more despairing view than we ought to have.

How much is the risk of developing an addiction genetic?

Genes affect us a lot. Studies across addictions show a genetic contribution. It varies by the substance, but at least 30 percent, sometimes even 50 percent. How much control people have just in general — some people are more impulsive than others, have a harder time thinking about the future than others from their first day on this Earth. And that will increase your risk for addiction.

If you’re very, very risk averse person who thinks a lot about the future, drug use looks differently to you than if you’re someone who wants to feel good today and is a happy go lucky person. Some of why we get addicted has to do with things that nobody can really control. And those can be things like liking. Even for the first time we use them, we like drugs differently.

When my boys were little, they were in the backyard, and they were climbing a tree. And I said, ah, that’s not how to climb a tree. I’ll show you how to climb a tree. So when I got to the emergency room, I said, this bone is broken. And I know it because I can see the way it’s knocked off my wrist.

And they nicely patched it for me. And they sent me home with Vicodin, the opioid Vicodin, bottle of 30, and said, it’s going to hurt. So you’re going to want to take these.

I take one. And I feel terrible. Stomach all feels bound up. I feel just really groggy. I don’t like this. For me, it was very easy to say pain is better than taking even one more of these pills. Meanwhile, I’ve treated people who say, the first time I had an opioid, it was like a hole that had been in my heart my whole life filled up for the first time.

Now, both those experiences are real. You cannot attribute them to, well, Keith must be a real solid and moral person, and that’s an immoral person, or Keith must have made good choices, and that person made bad choices, because we had no learning history at all. It was just the kismet of genetics that drugs feel differently to different people from the very first time, not just learning history.

And so I find it very easy to be sympathetic to someone who’s addicted to opioids because I think the reason I’m not going to do that is not because I’m a better person. It’s because they just don’t feel good to me. And to you, they felt fantastic. And so you were willing to keep on using them.

It’s not just that I find it easy to be sympathetic. But I find it hard to know how to think about it because, to be blunt, I’ve had very positive personal experiences with certain drugs. And at the same time, I’m somebody who is extremely nonaddictive in this area of my life. I have never wanted more puffs on a cigarette than I had. I’ve never smoked a cigarette and been like, I need another one. Obviously, other people I knew when I was in college, that was not how that went for them.

There is something here where, on the one hand, I worry that a fair amount of the discourse around drugs comes from people for whom maybe it actually is positive for them. There are people who have real positive relationships with different kinds of substances both legal and illegal. Adderall can be amazing for somebody with A.D.H.D., and it can be very destructive for somebody who ends up using it recreationally. I mean, you were talking about methamphetamines. And it’s not all that different.

And it becomes, I think, almost philosophically hard to know how to think about these substances that really can range. How to think about something where for some people it can be a very good part of their life, either pleasurable or even very profound. For other people, it can be a complete disaster that will actually ruin their life. And who are you making policy for and how feels like something that this conversation gets caught on a lot.

I agree, yeah, because drugs aren’t good, and drugs aren’t bad. They are good and bad. And sometimes I envy colleagues who work in areas like cholera prevention. If there’s a cholera outbreak, and you get rid of it, you’re a hero. Everybody loves you. Nobody says, but I was having a party. I need a little cholera. Can’t you keep a little cholera for special occasions? It’s like, no, everyone just hates cholera. Drugs are absolutely not like that. People have great experiences with drugs. I drink wine, by the way. That’s a drug. Or ethanol is a drug.

So we can’t resolve it that simply. And so we have to get into these questions of, well, when is it good? And when is it bad? And for whom is it good? And for whom is it bad?

And then there’s a question that is to me a philosophical question, in fact, religions grapple with, which is should I give something up for the benefit of others? Perhaps I can use fentanyl freely and enjoy it. But should I still say it shouldn’t be in recreational market because I’m aware enough of my fellow people would find it life ruining? And so the moral thing is for me to give it up so the sense that all of us can live together in a spirit of common humanity. And there’s always going to be tougher discussions, things that are good and bad versus things that are just clearly good, and we should just embrace them, and clearly bad and just reject them.

I wonder about this with the rollout of legal cannabis across a lot of the country. So this is something that I occasionally take. I’ll sometimes have a 5 milligram edible to help me sleep or to relax at the end of the night. It isn’t something I want all that often. And when I go into these stores, and I look in them, and I see the way they’re popping up in New York the way they popped up in California, it’s pretty clear this market is not catering to me.

And I think a lot about something that, as you mentioned, our mutual late friend Mark Kleiman, who was one of the great drug researchers and crime researchers, used to say to me, which is that alcohol companies do not make their money on people who drink a beer or two a week. They make their money on people who drink a case. And when I go into these stores, what I see are the rise of super high potency products that I wouldn’t touch. And clearly the money is being made given how many of the stores there are on people taking a lot more than I am a lot more often. When you look at what is going on with legal cannabis, how do you feel about it?

So start at the question of should we ever throw people in a cell for cannabis? Oh, so that was a terrible idea. So let’s take that off the table and just say if we’re going to have a legal industry, have we regulated it well? And I think it’s absolutely clear we have not.

And this is something we’re generally I’d say bad at relative to other countries of constraining profit when the profit damages public health. And so we have an industry with hardly any constraints on their products, not a very good record with even labeling their products accurately, very poor enforcement of even keeping the legal regime in place. And the pot shops in New York are a good example of that. A huge number of them are unlicensed and just doing whatever they want. And they’re being allowed to do that.

So I think we’ve done a really bad job with cannabis and in part driven by this phenomenon of not being willing to admit that cannabis isn’t good or bad, but it is both. And so when Mark Kleiman and I worked with Washington state, who was one of the first states to legalize, and we said, you still need to have some enforcement to make a licensing system work, I remember people literally either laughing or getting angry at us saying, the war on drugs is over. No more enforcement ever.

It’s like, actually, no. Why would you have a license and do the right thing and not hire minors? And why would you be sure to card? And why would you sell clean and safe products when you do that because you get a market advantage in a licensed market? And so if we just allow anybody to do anything, well, then there’s really no point in getting licensed, no point in paying your taxes, no point in being a good citizen, no point in not in hawking dangerous products.

And that’s the situation that we have. And we’re going to be really sorry for it. The distribution of consumption is also really important to think about. It’s not quite half, but it’s certainly a plurality of cannabis users today are using it every single day, usually a high strength product.

Wow, really? Almost half?

Yeah. I’d say about 40 percent are daily or near daily users. And so that’s where the money is if you’re running an industry. And so you want to produce cheap high-strength product that that population will use and use and use and use. And I just think we’re really going to regret that.

My friends over at “Search Engine,” which is a great podcast, just did this two part series on the New York cannabis market. And I had not really understood that while New York is now completely full of what appeared to me to be legal cannabis stores, virtually none of them are legal cannabis stores. There’s a very small number of legal ones and then a huge number of illegal ones.

And you might say, well, how are there all these illegal stores? And the answer is that nobody wants to send the police to bust people for cannabis. And so much of the theory of legalization as I understood it for years was that we will legalize and then be able to regulate the market. But if what we’ve done is legalized, but we’re not willing to use law enforcement, and so we cannot regulate the market, that’s actually a dramatically different policy equilibrium than I feel like I was promised.

Yeah, the experience you’re having — I think people have had across a lot of drug policy — is expecting one thing and then getting another and underestimating the ideological commitments of the people who designed it. So there are people who say, we’re going to have this legal market, and we’ll get rid of the illegal sellers and all that. But that isn’t what necessarily they wanted. They just thought, look, this should not be restricted at all. And you should just be able to deal with it and sell it and have a classic Libertarian understanding of it as opposed to a more progressive understanding of what we expect from industries. And this problem is replicated all over the country.

There’s also something that’s happened in policing, which is there’s always more to do for police than they have to do. So they’re not super interested in getting involved. Even with some of the massive problems we have, for example, here in California, we have huge illicit groves, some of them staffed by people who have literally been human trafficked. But it hasn’t really risen up as an enforcement priority because, cannabis, we don’t do that anymore.

You said this about cannabis, and I found it really striking. Quote, “The newly legal industry looks a lot like the tobacco industry — an under-regulated, under-taxed, politically connected, white dominated corporate entity that generates its profits mainly by addicting lower income people to a drug. 85 percent of Colorado’s cannabis, for example, is consumed by people who did not graduate from college.” Can you say a bit more about that socioeconomic breakdown?

Yeah. So I think that in middle upper class society, that figure’s really shocking. And the idea is, oh, cannabis user is, oh, someone like you, someone who has a good job, went to college, and maybe uses occasionally. No. I say if you want to think of the typical user, think of somebody who works in a gas station who gets high on all their breaks. That’s much more the sociodemographic breakdown of it.

And by the way, that’s what you see with tobacco as well. In my professional middle class life, it is so rare for me to see somebody smoking a cigarette. But if you go into a poor neighborhood, there’s still a lot of people who smoke cigarettes.

And so we’ve won the war on smoking I guess, middle class and well off. But it’s far less the case as you move into people who have much more challenging lives. And this comes back to the point that you raised and I think is really important one is that since that professional class makes the policies, it’s really important for them to remember that their lives are different than the people whose lives will be most profoundly affected by those policies.

One thing that a lot of drugs, cannabis being one of them, do is allow you to escape from a life that doesn’t feel good to you. If I had a job that bored the hell out of me, it might be more appealing to use something like cannabis more often. I really like my job. And I definitely cannot do it high, so I don’t. But there’s both a question of how does this affect you as a person but also how much might you want it, need it, need the escape?

I think this gets down to one of the most important questions to ask, which is, why don’t more people use drugs? People say, why does anybody use drugs? And it’s like, well, do you ask me why anybody has sex? That’s a really strange question. It feels good. We don’t need an explanation why people use them.

It’s actually far more interesting to think, why aren’t we all using them? Why aren’t you and I using drugs right now? And big reasons why are, well, we have other rewards in our lives. And we have a lot of other stuff that we want to do that is rewarding.

So in the absence of those things, the why not question, the answer seems to be, well, I can’t think of a reason why not. I might as well. Well, you won’t live as long. Well, I don’t expect to live that long. You won’t do well in your brilliant career. I don’t have a brilliant career. You won’t enjoy your fabulous house. I don’t have a fabulous house.

And that’s a reason I think it’s easy or it should be easy to have some sympathy. We all don’t have the same set of rewards to choose from. Rewards any neuroscientists would tell you are judged relative to each other. We don’t just make judgments over good, bad, but we do a lot of this is better than that. So as you pull rewards out of an environment, yeah, drugs become relatively more appealing.

It feels to me across this conversation that we’re talking about two eras that didn’t really work. I think a lot of people are worried about just a pendulum swinging between extremes. I’m curious if to you there is a synthesis out there either in a place or in a theory that feels like it balances these different realities, that people will use drugs? They are good for some people and terrible for others, that we don’t want to be throwing adults constantly into jail because they did something with their own bodies. We don’t want tons of people to get addicted because we decided not to throw anybody in jail. Is there something that feels to you like it strikes a balance here?

So years ago, when I worked for President Obama, we cited Washington’s example because they had taken a couple of hundred million dollars, spent it on mental health and substance use treatment, and showed within 12 months they’d actually made all their money back because of less crime, because of less disability, because of less trips to the emergency room. And importantly, they had gathered data to show that. And that was one of the things we used when the Affordable Care Act was being done to explain why covering substance use in that package would be a good deal for the taxpayer in addition to, of course, being a good deal to any person who had that problem.

There’s also certain issues where people with very different views and feelings about drugs can agree. So I’ve been working with a lot of people around the country on building Medicaid into the correctional system starting in California. It was pushed by a fabulous assembly member named Marie Waldron. We turn Medicaid on before people leave. And that gets them typically on some type of medication. And that can pull people together because it makes it far less likely for them to die of an overdose or to have other health problems. And it also makes them much less likely to commit crimes. And so you can get people like, well, I’m not very sympathetic. I don’t want to spend money on the health of some drug user. But if it makes them less likely to commit more crime, I like that. And other people say, well, this is a health matter. It’s like, well, then they like it too.

And that approach, which now multiple states have been approved for and the Biden administration C.M.S. has said, you can all have this Medicaid waiver — I don’t know the current number. I think it’s about 14 or 15 other states are applying. And as an example of something where you don’t necessarily have to resolve all the disagreements, but you can find a policy that maximizes multiple outcomes that a broad section of people care about.

Something I’ve seen you talk about and write about is this idea that the way that policing should work here is it should be very, very predictable, very certain you will get picked up, and very modest. It’s sort of almost like it operates as a constant annoyance. You end up in jail for 24 hours and are let loose. And there was some evidence that definitely did decrease repeat offending not among everybody but among enough people to really matter in the study. Do you still think that’s a good idea?

Absolutely. It’s a good principle for enforcement and for deterrence to have it be predictable, responsive, and fair. There’s been a lot of success with drink driving and alcohol through the program 24/7 Sobriety, which started in South Dakota and has now spread to about 15, 20 states and is also now in other countries.

It’s all across England, all across Wales where I was just last week actually working on that, which is a model whereby people are sentenced after their second, third, fourth, fifth alcohol related arrest to not be allowed to drink. They aren’t sent to jail. They aren’t fine. Their cars aren’t taken away. But their alcohol use is monitored literally every single day with swift and certain but modest consequences if they drink.

And that program has reduced incarceration. It has reduced crime. It has reduced domestic violence. And it strikes a good balance between using the criminal justice system to protect and put some constraints on people but not in a way that ends up being carceral.

And the place where we can really make a huge impact on that in the United States is the million people we’re already supervising on probation and parole who have substance use problems. And we need to roll those out more broadly. For example, Oregon’s new policy mix if implemented properly, which will be a challenge, I think it would be a very good one. They do put pressure on people to seek treatment. But they say literally, no one is going to be put into a prison in Oregon simply because they used a drug. And now they’re building up the other part you got to have, which is have to have the health system and the services that keep people alive while they use and then help them get into recovery. That, I think, is a very appealing mix of things.

We have a really hard time, I think, in the U.S. and lots of policy issues of realizing that it’s not a series of on/off switches. It’s a series of dials. And you can adjust things and find sensible, nuanced approaches that are more effective than what fits on a bumper sticker.

And I feel like that’s what my job is. And people like me who do not have to take the great risk to stand up and people and say, please vote for me. And then that means I have to explain something simply. It can’t be any other way but are next to it and are very fortunate to have the time to sift through evidence in a calm environment before they venture out with some suggestions about what we might do better.

I think that’s a good place to end. So then as a final question, what are three books you would recommend to the audience?

So there’s so many good books written about in this area. It’s hard to pick. So I decided to prioritize personal relationship starting with your late friend of mine Mark Kleiman, who wrote a book called “Drugs and Drug Policy: What Everyone Needs to Know,” coauthored with Jonathan Caulkins and Angela Hawken.

And it is exactly what the title promises. It’s accessible. It’s something you can dip into and out of and answer any question you want. And I also point to it as just a model of how academics in any area can write in such a fashion that a broad audience can engage their work and learn from it.

The second book I would suggest, again, from a friend who’s someone I’ve known since she was a psychiatric resident and I was an assistant professor. And that’s Dr. Anna Lembke here at Stanford. And the book is called “Dopamine Nation,” which was a deserved bestseller around the world.

But that gives you much more of the human experience describing, what is it like to be addicted, to not be able to stop doing something even though you know it’s destructive? How does it feel? How do you try to overcome it? And what is going on in that person neurologically that makes it so hard? And then the book also talks about just the seeking of reward in a reward saturated society and how we all are chasing all these things, whether it’s on our cell phones or with drugs and so on.

And then the last one — maybe a more eccentric choice, but it’s such a good book — is by Thomas De Quincey. And it’s called “Confessions of an English Opium Eater.” So De Quincey was a hangers on of the romantic poet set about 200 years ago in England. And he wrote at the time a very scandalous account. But, of course, also scandalous things in Britain are often very popular things.

So it became a bestseller about his experience of long time opium use. And he talks about the pains of opium and the pleasures of opium and a bit about how it affects social relationships, how it affects human psychology. And what I like about is, first off, it has a wonderfully florid over the top poetic style. And the other thing is almost everything you and I have talked about today is touched on in that book. And that shows that while we do learn things and we go forward with science, with policy, it is also true that the human relationship with drugs has had the same benefits and challenges in it for time immemorial. And so that’s a reminder of that when you read a book written that long ago and can resonate with so much of what’s going on today.

Keith Humphreys, thank you very much.

The show’s production team also includes Rollin Hu and Kristin Lin. Original music by Isaac Jones. Audience strategy by Kristina Samulewski and Shannon Busta. The executive producer of New York Times Opinion Audio is Annie-Rose Strasser. Special thanks to Sonia Herrero.

May 10, 2024 • 1:02:30 This Is a Very Weird Moment in the History of Drug Laws
May 7, 2024 • 1:04:33 Watching the Protests From Israel
April 30, 2024 • 1:03:00 Cows Are Just an Environmental Disaster
April 26, 2024 Salman Rushdie Is Not Who You Think He Is
April 23, 2024 • 56:06 This Conversation Made Me a Sharper Editor
April 16, 2024 • 49:17 A $1.7 Million Toilet and Liberalism’s Failure to Build
April 12, 2024 • 1:33:07 What if Dario Amodei Is Right About A.I.?
April 5, 2024 • 1:25:33 Will A.I. Break the Internet? Or Save It?
April 2, 2024 • 1:14:31 How Should I Be Using A.I. Right Now?
March 29, 2024 • 1:18:30 The Rise of ‘Middle-Finger Politics’
March 22, 2024 • 1:08:32 The Deep Conflict Between Our Work and Parenting Ideals
March 19, 2024 • 1:03:11 Birthrates Are Plummeting Worldwide. Why?

Produced by ‘The Ezra Klein Show’

Drug policy feels very unsettled right now. The war on drugs was a failure. But so far, the war on the war on drugs hasn’t entirely been a success, either.

Take Oregon. In 2020, it became the first state in the nation to decriminalize hard drugs. It was a paradigm shift — treating drug-users as patients rather than criminals — and advocates hoped it would be a model for the nation. But then there was a surge in overdoses and public backlash over open-air drug use. And last month, Oregon’s governor signed a law restoring criminal penalties for drug possession, ending that short-lived experiment.

Other states and cities have also tipped toward backlash. And there are a lot of concerns about how cannabis legalization and commercialization is working out around the country. So what did the supporters of these measures fail to foresee? And where do we go from here?

[You can listen to this episode of “The Ezra Klein Show” on the NYT Audio App , Apple , Spotify , Amazon Music , YouTube or wherever you get your podcasts .]

Keith Humphreys is a professor of psychiatry at Stanford University who specializes in addiction and its treatment. He also served as a senior policy adviser in the Obama administration. I asked him to walk me through why Oregon’s policy didn’t work out; what policymakers sometimes misunderstand about addiction; the gap between “elite” drug cultures and how drugs are actually consumed by most people; and what better drug policies might look like.

You can listen to our whole conversation by following “The Ezra Klein Show” on the NYT Audio App , Apple , Spotify , Google or wherever you get your podcasts . View a list of book recommendations from our guests here .

(A full transcript of this episode is available here .)

This episode of “The Ezra Klein Show” was produced by Annie Galvin. Fact-checking by Michelle Harris, with Kate Sinclair and Mary Marge Locker. Our senior engineer is Jeff Geld, with additional mixing by Aman Sahota and Efim Shapiro. Our senior editor is Claire Gordon. The show’s production team also includes Rollin Hu and Kristin Lin. Original music by Isaac Jones. Audience strategy by Kristina Samulewski and Shannon Busta. The executive producer of New York Times Opinion Audio is Annie-Rose Strasser. Special thanks to Sonia Herrero.

Follow the New York Times Opinion section on Facebook , Instagram , TikTok , WhatsApp , X and Threads .

IMAGES

Argumentative Essay about Why Smoking Should be Banned
Paper 1
One-Third of U.S. Cancer Deaths Due to Cigarette Smoking, Study Finds
Smoking Kills by Conrad Keating
How smoking effects others more than you essay example
Smoking Kills… By Destroying Your Body * Every Cigarette You

VIDEO

Essay on smoking in public places should be banned || Essay writing in English|| essay writing
10 lines on smoking in hindi/dhumrapan per nibandh
Smoking kills, but smoking ads
Essay on Smoking in Urdu
PROFOUND MGS ANTI SMOKING MESSAGE???? (GONE WRONG) (2SMART4U)
Essay on Smoking for students || Essay

COMMENTS

Essay on Smoking in English for Students
500 Words Essay On Smoking. One of the most common problems we are facing in today's world which is killing people is smoking. A lot of people pick up this habit because of stress, personal issues and more. In fact, some even begin showing it off. When someone smokes a cigarette, they not only hurt themselves but everyone around them.
Tobacco Smoking and Its Dangers
Introduction. Tobacco use, including smoking, has become a universally recognized issue that endangers the health of the population of our entire planet through both active and second-hand smoking. Pro-tobacco arguments are next to non-existent, while its harm is well-documented and proven through past and contemporary studies (Jha et al., 2013).
Examples & Tips for Writing a Persuasive Essay About Smoking
Persuasive Essay Examples About Smoking. Smoking is one of the leading causes of preventable death in the world. It leads to adverse health effects, including lung cancer, heart disease, and damage to the respiratory tract. However, the number of people who smoke cigarettes has been on the rise globally. A lot has been written on topics related ...
Tobacco
Tobacco kills more than 8 million people each year, including an estimated 1.3 million non-smokers who are exposed to second-hand smoke (4). Around 80% of the world's 1.3 billion tobacco users live in low- and middle-income countries. In 2020, 22.3% of the world's population used tobacco: 36.7% of men and 7.8% of women.
235 Smoking Essay Topics & Titles for Smoking Essay + Examples
In your essay about smoking, you might want to focus on its causes and effects or discuss why smoking is a dangerous habit. Other options are to talk about smoking prevention or to concentrate on the reasons why it is so difficult to stop smoking. Here we've gathered a range of catchy titles for research papers about smoking together with ...
Introduction, Conclusions, and the Evolving Landscape of Smoking
Tobacco smoking is the leading cause of preventable disease, disability, and death in the United States (U.S. Department of Health and Human Services [USDHHS] 2014). Smoking harms nearly every organ in the body and costs the United States billions of dollars in direct medical costs each year (USDHHS 2014). Although considerable progress has been made in reducing cigarette smoking since the ...
Smoking: Effects, Risks, Diseases, Quitting & Solutions
Smoking is the practice of inhaling smoke from burning plant material. Nicotine works on your brain to create a relaxing, pleasurable feeling that makes it tough to quit. But smoking tobacco puts you at risk for cancer, stroke, heart attack, lung disease and other health issues. Nicotine replacements and lifestyle changes may help you quit.
Argumentative Essay on Smoking Cigarettes
The dangers of smoking cigarettes have been well-documented, yet millions of people continue to engage in this harmful habit. The debate over the impact of smoking on public health is ongoing, with some arguing for stricter regulations and others advocating for personal freedom. In this essay, we will explore the various arguments surrounding smoking cigarettes and ultimately make the case for ...
Health Effects of Cigarette Smoking
Smoking causes stroke and coronary heart disease, which are among the leading causes of death in the United States. 1,3. Even people who smoke fewer than five cigarettes a day can have early signs of cardiovascular disease. 1. Smoking damages blood vessels and can make them thicken and grow narrower.
Writing a Smoking Essay. Complete Actionable Guide
Whether you are writing a teenage smoking essay or a study of health-related issues, you need to stay objective and avoid including any judgment into your assignment. Even if you are firmly against smoking, do not let emotions direct your writing. You should also keep your language tolerant and free of offensive remarks or generalizations.
Why is smoking bad for you?
Smoking also damages the blood vessels, making them thicker and narrower. This makes it harder for blood to flow, and also increases blood pressure and heart rate. Smoking has links with the ...
PDF A White Paper on Tobacco
Smoking Kills - A White Paper on Tobacco Chapter 1 Smoking kills 1.1 Smoking kills. Smoking is the single greatest cause of preventable illness and premature death in the UK. Smoking kills over 120,000 people in the UK a year - more than 13 people an hour1. Every hour, every day. For the EU as a whole the
Smoking kills
Tobacco smoking is the largest cause of preventable illness and death in Australia. Smoking causes a range of cancers, as well as heart disease, stroke and emphysema. Many people die from smoking . Tobacco causes more illness and death than any other drug. In Australia, smoking kills around 18,800 people every year.
SMOKING KILLS essays
987 Words. Smoking is bad for your body and your overall health. There are many side affects that can hurt and even kill your body. It also can harm your lungs and make it hard for you to breathe. When you look at the statistics I don't understand why people do smoke. Cigarette smoking is the most important preventable cause of premature death ...
Smoking Kills Essay
Essay on Smoking Risks. One of the most popular habits in today's society is smoking. Yet each year, cigarette smoking kills more Americans than AIDS, alcohol, car accidents, homicides, suicides, illegal drugs and fires combined.
Smoking Kills
Essay Smoking Kills Ellyn Coe University of Essex Abstract A short story about a man and woman. Keywords: Fiction, sort story. Story With the habitual ease of fifty-seven years of doing so, they sat together in the familiar comfort of well-worn cushioned seats, moulded to the shape of their wizened backsides.
How Smoking Kills Human Body
How Smoking Kills Human Body. This essay sample was donated by a student to help the academic community. Papers provided by EduBirdie writers usually outdo students' samples. Smoking is a bad habit that is usually done to reduce stress and anxiety. It is believed by most people that nicotine—a drug inside tobacco can help calm frustration ...
Argumentative Essay about Smoking
Introduction. Smoking is a really bad habit that engulfs millions of people each year and is killing many lives despite attempts by the government and individuals trying to stop it. Smoking is the cause of many cancers and causes permanent damage to the human body. So why don't we change the legal age to have cigarettes?
Smoking Kills Essay Example For FREE
In addition to toxic chemicals, the smoke inhaled from cigarette contains substances that cause cancer and damage to vital organs such as the heart, lungs, and kidneys. Third, the addictive effects of cigarette smoking can cause specific level of your performance. These are considered of a smoker's behavior altering, psychoactive and abuse able.
Rhetorical analysis on Smoking Ad
This "Smoking Kills" ad uses multiple different forms of rhetoric effectively. The picture displays a middle-aged man shaving his face while having to avoid cutting is Stoma, which is a result of throat cancer. The ad uses Ethos, Logos, and Pathos to attempt to persuade the viewer that this is a possible outcome of smoking cigarettes.
Smoking Kills Essay
Smoking Kills Essay - Free download as PDF File (.pdf), Text File (.txt) or read online for free. Scribd is the world's largest social reading and publishing site.
Free Essay: Smoking Kills
Many smokers personal appreance is highly affected by smoking cigarettes. 1. Smoking causes a person to have bad breath. 2. Yellow teeth. 3. Bad smelling hair and clothing. Smoking increases the risk of developing Crohn's disease (CD) but not the risk of ulcerative colitis (UC).
Smoking Kills Essay.pdf
Smoking Kills Essay Writing an essay on the topic "Smoking Kills" can present a challenging yet crucial task. The difficulty lies not only in the need to convey factual information about the detrimental effects of smoking but also in crafting a compelling argument that resonates with the audience. One must delve into extensive research to ...
This Is a Very Weird Moment in the History of Drug Laws
Timothy Archibald. This episode of "The Ezra Klein Show" was produced by Annie Galvin. Fact-checking by Michelle Harris, with Kate Sinclair and Mary Marge Locker. Our senior engineer is Jeff ...