smoking report essay

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Essays About Smoking

Smoking essay, types of essay about smoking.

Cause and Effect Essay: This type of essay focuses on the causes and effects of smoking. It discusses why people start smoking and the consequences of smoking on both the smoker and those around them.
Argumentative Essay: This essay type aims to persuade the reader about the negative effects of smoking. It presents an argument and provides supporting evidence to convince the reader that smoking is harmful and should be avoided.
Persuasive Essay: Similar to an argumentative essay, this type of essay aims to persuade the reader to quit smoking. It presents facts, statistics, and other relevant information to convince the reader to stop smoking.

Smoking Essay Example: Cause and Effect

Identify the causes of smoking: Start by examining why people start smoking in the first place. Is it peer pressure, addiction, stress, or curiosity? Understanding the reasons why people smoke is crucial in creating an effective cause and effect essay.
Discuss the effects of smoking: Highlight the impact smoking has on an individual's health and the environment. Discuss the risks associated with smoking, such as lung cancer, heart disease, and respiratory problems, and explain how smoking affects non-smokers through secondhand smoke.
Use reliable sources: To make your essay more convincing, ensure that you use credible sources to back up your claims. Use scientific studies, government reports, and medical journals to support your arguments.
Provide statistical evidence: Incorporate statistical data to make your essay more impactful. Use figures to show the number of people who smoke, the effects of smoking on the environment, and the costs associated with smoking.
Offer solutions: Conclude your essay by suggesting solutions to the problem of smoking. Encourage smokers to quit by outlining the benefits of quitting smoking and offering resources for those who want to quit.

Smoking: Argumentative Essay

Choose a clear position: The writer should choose a side on the issue of smoking, either for or against it, and be clear in presenting their stance.
Gather evidence: Research and collect facts and statistics to support the writer's argument. They can find data from reliable sources like scientific journals, government reports, and reputable news organizations.
Address counterarguments: A good argumentative essay will acknowledge opposing viewpoints and then provide a counterargument to refute them.
Use persuasive language: The writer should use persuasive language to convince the reader of their position. This includes using rhetorical devices, such as ethos, pathos, and logos, to appeal to the reader's emotions and logic.
Provide a clear conclusion: The writer should summarize the key points of their argument and reiterate their stance in the conclusion.

Persuasive Essay on Smoking

Identify your audience and their beliefs about smoking.
Present compelling evidence to support your argument, such as statistics, research studies, and personal anecdotes.
Use emotional appeals, such as stories or images that show the negative impact of smoking.
Address potential counterarguments and refute them effectively.
Use strong and clear language to persuade the reader to take action.
When choosing a topic for a smoking persuasive essay, consider a specific aspect of smoking that you would like to persuade the audience to act upon.

Hook Examples for Smoking Essays

Anecdotal hook.

Imagine a teenager taking their first puff of a cigarette, unaware of the lifelong addiction they're about to face. This scenario illustrates the pervasive issue of smoking among young people.

Question Hook

Is the pleasure derived from smoking worth the serious health risks it poses? Dive into the contentious debate over tobacco use and its consequences.

Quotation Hook

"Smoking is a habit that drains your money and kills you slowly, one puff after another." — Unknown. Explore the financial and health impacts of smoking in today's society.

Statistical or Factual Hook

Did you know that smoking is responsible for nearly 8 million deaths worldwide each year? Examine the alarming statistics and data associated with tobacco-related illnesses.

Definition Hook

What exactly is smoking, and what are the various forms it takes? Delve into the definitions of smoking, including cigarettes, cigars, pipes, and emerging alternatives like e-cigarettes.

Rhetorical Question Hook

Can we truly call ourselves a smoke-free generation when new nicotine delivery devices are enticing young people? Investigate the impact of vaping and e-cigarettes on the youth.

Historical Hook

Trace the history of smoking, from its ancient roots to its prevalence in different cultures and societies. Explore how perceptions of smoking have evolved over time.

Contrast Hook

Contrast the images of the suave, cigarette-smoking characters from classic films with the grim reality of tobacco-related diseases and addiction in the modern world.

Narrative Hook

Walk in the shoes of a lifelong smoker as they recount their journey from that first cigarette to a battle with addiction and the quest to quit. Their story reflects the struggles of many.

Shocking Statement Hook

Prepare to uncover the disturbing truth about smoking—how it not only harms the smoker but also affects non-smokers through secondhand smoke exposure. It's an issue that goes beyond personal choice.

The Harmful Effects of Smoking: Physical, Social, and Economic Consequences

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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.

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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 .

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

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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.

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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.

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Essay on Smoking

Smoking Report Essay Samples

Type of paper: Essay

Topic: Smoking , Australia , Tobacco , Smokers , In Australia , Health , Statistics , Smoke

Words: 1600

Published: 03/08/2023

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Smoking is a widely prevalent hazardous habit that can predispose the smoker and the nearby passive smokers to a number of chronic diseases like cancer and cardiopulmonary disorders. One third of the world population are smokers. There are more than 1 billion male smokers and 250 million female smokers. Smoking rates are higher in industrialized countries, when compared to developing countries. Nevertheless, the phase of increase in smoking rate is higher in developing countries, while decreasing rates were observed in developed countries. According to World Health Report, smoking accounts for 3 million deaths annually ("Smoking Statistics", 2016). According to the WHO statistics, 15 billion cigarettes are sold every day. The number of cigarettes sold per day is more than twice the total population of human being. As per WHO statistics ~ 41% men and ~ 22% women use tobacco. While smoking is predominantly a male habit, the gap between smoking in males and females is less in countries like U.K, Denmark, Austria, Ireland, and Norway. The highest prevalence of smokers among all countries in the world is reported in Greece, Serbia, Russia and Bulgaria. Australia ranks 50 in the world, U.S ranks 51 and U.K ranks 74 in the world highest level of smokers. ("Smoking Statistics", 2016) WHO has also identified an increasing trend in the use of tobacco among women. As countries have begun to understand the ill effects of smoking and started to implement strict policies like increasing taxes on tobacco products and banning use of tobacco in a public place, a change is expected in tobacco usage. At present there is no data on how the anti-tobacco policies have affected the number of people who smoke. In Australia, tobacco caused ~ 15,000 deaths every year, as per the 2005 statistics. According to the estimates of the Australian government, the sales of tobacco products in 2013 were 3.5 billion. This was ~0.1 billion tobacco products lesser than the sales in 2012. It has been identified as the leading cause of most preventable deaths and diseases in Australia . Half of all long term smokers, die from smoking associated diseases. Lung cancer is the leading cause of death among male and female smokers in Australia. Lung cancer is the leading cause of cancer in Australia. In 2013, the smoking rate among Australian men was 17% and in women was 13%. According to the 2013 National Drug Strategy Household Survey, the percentage of smokers aged 14 years or older in the total population were 12.8%. In 1991, it was 24.3%. There has been a considerable decrease in the percentage of smokers from 1991 to 2013. (Creative, 2016) The prevalence of smoking shows varying trends across different states in Australia (Table 1). The prevalence of current smokers was highest in the Northern Territories (24%), followed by Tasmania (18%), Queensland (17%) and the lowest prevalence is reported in Australian Capital Territory (12%). A significant decline in smoking rates have been observed in all states except the Northern Territories. The level of smoking in Northern Territories has remained consistently higher since 2001. ("1.14 Smoking by Australian states and territories - Tobacco In Australia", 2016) The tobacco smoke consists of carbon monoxide, hydrocyanic acid, acetaldehydes, acrolein, ammonia, formaldehyde, oxides of nitrogen, nitrosamines, hydrazine vinyl chloride, etc. All these gases and compound are detrimental to health. A majority of these chemicals are carcinogenic. Nicotine and tar in tobacco smoke also cause serious harm to the body. Regular smoking causes addiction to nicotine. This necessitates regular smoking, to maintain the level of nicotine in the blood and to avoid discomfort. ("Department of Health | Tobacco key facts and figures", 2016) The smoking rate among young adults in 2013 was 13%. It has decreased, considerably from 19% in 2001. According to the NDSHS survey, the age at which the individual starts smoking has increased from 15.4 years to 15.9 years. In 2013, 95% of the children aged 12 to 15 years, did not smoke. ("Smoking statistics", 2016) The smoking rates in aboriginal are more than twice of that present in the non-indigenous population. Smoking rates are high among people from the low education group and low socioeconomic groups. Individuals aged 14 years and older are three times more likely to be smokers, than people with high socioeconomic status. Similarly, employed people are less likely to smoke than unemployed people. The smoking rate among people in rural communities was two times higher than in urban communities. ("Smoking statistics", 2016) Tobacco smoke not only harms the smoker, but can also affect the health of people who passively inhale the smoke, and it is also harmful to the environment. It can cause sudden death syndrome in infants and can also sensitize children to respiratory problems. Smoking is an important public health concern and there has been an overall decreasing trend in the use of tobacco in Australia. There has also been a decrease in the smoking rate among the aboriginal and Torres strait islander. An important reason for this favorable trend, are the efforts of the Australian government’s tobacco control program. Public education campaigns, and awareness created by the media, has helped in educating the masses on the problem. Similarly, implementing high taxes, and increasing the price of tobacco products, has helped in discouraging its use. The ban on advertising tobacco products has also contributed to decreasing the popularity of the habit, in the population. The government also promoted smoke free environment by imposing a ban on smoking in public places. All these efforts have contributed to the changing scenario seen in Australia. Though the legal age for purchasing tobacco is 18years in Australia, current smoking rates were 5% in male and 9% in females, aged 15-17 years ("4125.0 - Gender Indicators, Australia, Jan 2013", 2016). Though smoking rates have decreased, it still prevalent at levels that are sufficient to cause health concerns in the population. Though awareness, taxes and bans can help prevent new smokers, the old smokers have a hard time quitting. Thus, there is a need for a group to help chronic smokers quit smoking. Australia has a national team that helps citizens with quitting tobacco. Like any substance abuse, smoking is also associated with a ‘cold turkey’ phase, where the body craves for nicotine and thus the feeling of anxiety, irritability and hunger. There are no official statistics on the prevalence of smoking in the year 2015, and thus the prominence of the problem today, cannot be identified. Nevertheless, a more focused intervention for vulnerable groups like children, aboriginal population and those from low socioeconomic status, will help lower the prevalence of smoking. ("Quitting smoking - Cancer Council Australia", 2016) Smoking causes serious health and economic loss to the nation. Smoking in the presence of other occupational pollutants like asbestos, radiation, or cotton can act as additive or multiplicative occupational hazard. In pregnant women, smoking is associated with growth retardation and mental retardation in children. Smoking can also affect the psychology of the person. Studies indicate that children of parents who smoke are more likely to become smokers when compared to children of non-smoking parent. Conclusion: There are more than ~ 1.1 billion smokers in the world and it is expected to increase to 1.6 billion in 2025. As per WHO statistics ~ 41% men and ~ 22% men use tobacco product worldwide. In Australia, the statistics is based on smokers count and thus it is difficult to compare with overall prevalence worldwide. In 2013, the smoking rate among Australian men was 17% and in women it was 13%. Though there has been an overall decline in smokers in Australia, it is still a health concern, and an important cause of many chronic diseases in Australia. Certain states like the Northern Territories, continue to show increased trends. There is a need for focused smoking awareness campaign, and further research would be needed, to understand the reason for the high prevalence of smoking in this territory. Unemployment and lack of education may be positively associated with smoking in these regions.

Abbreviation: NSW-New South Wales, Vic-Victoria, Qld-Queensland, WA-Western Australia, SA-Southern Australia, Tas-Tasmania, ACT-Australian Capital Territory, and NT-Northern Territory.

Ref: ("1.14 Smoking by Australian states and territories - Tobacco In Australia", 2016)

1.14 Smoking by Australian states and territories - Tobacco In Australia. (2016). Tobaccoinaustralia.org.au. Retrieved 24 March 2016, from http://www.tobaccoinaustralia.org.au/1-14-smoking-states-territories 4125.0 - Gender Indicators, Australia, Jan 2013. (2016). Abs.gov.au. Retrieved 24 March 2016, from http://www.abs.gov.au/ausstats/[email protected]/Lookup/4125.0main+features3320Jan%202013 Creative, B. (2016). Smoking in Australia -Â ACOSH Australian Council on Smoking and Health - The epidemic of smoking in Australia continues. Acosh.org. Retrieved 24 March 2016, from http://www.acosh.org/smoking-in-australia/ Quitting smoking - Cancer Council Australia. (2016). Cancer.org.au. Retrieved 24 March 2016, from http://www.cancer.org.au/preventing-cancer/smoking-and-tobacco/quitting-smoking.html Smoking statistics. (2016). www.gov.au.betterhealth.vic.gov.au. Retrieved 24 March 2016, from https://www.betterhealth.vic.gov.au/health/healthyliving/smoking-statistics Smoking Statistics. (2016). WHO Western Pacific Region. Retrieved 24 March 2016, from http://www.wpro.who.int/mediacentre/factsheets/fs_20020528/en/ Who is smoking? (2016). Euro.who.int. Retrieved 24 March 2016, from http://www.euro.who.int/en/health-topics/disease-prevention/tobacco/data-and-statistics/who-is-smoking

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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].

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Free Essay Samples

Essays on Smoking

Essay-writers in each smoking essay emphasize the dangers of smoking, and fairly so. After all, smoking is one of the most widespread bad habits in the world – there are about 2 billion smokers worldwide. It is a detrimental habit, as cigarette smoke contains more than 30 toxic components – you can go into them one by one in your essays on smoking. It's no secret how dangerous smoking is, however, around 18 billion cigarettes are sold globally every day. Smoking essays often include a lot of statistics, as facts speak louder than opinions. An estimated $50 billion a year is spent on treating smoking-related diseases in the United States alone. This means that for every pack of cigarettes, about $2 are spent on treating smoking-related diseases. Crazy, right? If you need more info on smoking for your essays, review our smoking essay samples.

Smoking and its Impact on Health Smoking predisposes one to various health problems including cancer of the lung, addiction, and adoption of harmful behaviors. Amongst adult smokers, smoking patterns have shown no significant reduction and a possible rise in smoking in the young individuals and the preteens has been reported (Lando,...

Words: 1022

1. Do you agree with the no smoking law in all public buildings in the state of Illinois? Should other states pass this law? What are the physical effects of second hand smoke on a child's airway? Should smoking in the presence of young children be...

Smoking in Public Places: A Health Hazard Smoking in public places is a health hazard for the smokers as well as the non-smoking public. The main dangers of smoking in public are often health-related as well as accident fires. More fatalities arise from public smoking are connected to the adverse effects...

Words: 1538

The World Health Organization suggests that approximately 5 million people die every year in the world because of tobacco use. Further, the report argues that, “the use of tobacco may cause about one billion deaths in the 21st century if current trends continue” (World Health Organization, " Research for International...

The Health Risks of Public Smoking The ban on smoking in public spaces has been an ongoing topic of discussion in different health platforms all over the world. Every year, several people are reported to die from lung cancer and other smoking-related health conditions. Nonetheless, despite the several reported deaths, tobacco...

Words: 1695

The number of the individuals who smoke has risen over the years. Even though they are aware of how harmful smoking can be, the public still decides to use a cigarette. It is an individual decision, and it is a habit which is extremely addictive. It is not the responsibility...

Words: 1413

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The opening sentence The opening sentence used by the author does not induce vigor of reading the article. Words arrangement in the sentence is not right, it should have read, ‘Herbert A. Gilbert filed the first electronic cigarette for a patent in 1963.’ The writer assumes that the reader knows what...

The Importance of Tobacco Control Policies Over the years, tobacco smoking has become a worldwide concern for health. Thus, the US government alongside other countries has been on the move in passing policies and ordinances which control the use of tobacco. The health implications associated with tobacco smoking have been more...

Smoking is an endemic problem that not only affects smokers, but also goes as far as affecting innocent non-smoking public. At the core of this problem is the issue of smoking in public places. Being a risk to public health a ban on public smoking can be a life saver,...

Introduction Even though almost every smoker realizes the harm caused by smoking, the number of smokers in the world remains enormous. Due to a low price, availability, legality, and the promotion of cigarettes in the media, almost every second there is a new person that starts smoking. The main reason for...

Words: 1220

The cigarette is one of the deadliest drugs known to human beings. In the developed countries, there are attempts to minimize the smoking rates. There are different measures which have been suggested to help reduce the risks posed by consumption of the drug which includes increased taxes, bans on cigarette...

Words: 1017

The Question of Outlawing Cigarettes and Tobacco Products The question of whether cigarettes and other tobacco products should be outlawed is still an argument as many agree as well as disagree from the same. Tobacco is a plant which is grown and contains nicotine which affects one to be dependent on...

Words: 1040

Craft an Engaging Persuasive Essay About Smoking: Examples & Tips

Published on: Jan 25, 2023

Last updated on: Jan 29, 2024

Persuasive Essay-Defined

A persuasive essay is a form of academic writing that presents an argument in favor of a particular position, opinion, or viewpoint.

It is usually written to convince the audience to take a certain action or adopt a specific viewpoint.

The primary purpose of this type of essay is to provide evidence and arguments that support the writer's opinion.

In persuasive writing, the writer will often use facts, logic, and emotion to convince the reader that their stance is correct.

The writer can persuade the reader to consider or agree with their point of view by presenting a well-researched and logically structured argument.

The goal of a persuasive essay is not to sway the reader's opinion. It is to rather inform and educate them on a particular topic or issue.

Check this free downloadable example of a persuasive essay about smoking!

Simple Persuasive essay about smoking

Read our extensive guide on persuasive essays to learn more about crafting a masterpiece every time.

Persuasive Essay Examples About Smoking

Are you a student looking for some useful tips to write an effective persuasive essay about the dangers of smoking?

Look no further! Here are several great examples of persuasive essays that masterfully tackle the subject and persuade readers creatively.

Persuasive speech on the 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

For more examples about persuasive essays, check out our blog on persuasive essay examples .

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Argumentative Essay About Smoking Examples

Our examples can help you find the points that work best for your style and argument.

Argumentative essay about smoking introduction

Argumentative essay about smoking pdf

Argumentative essay about smoking in public places

10 Tips for Writing a Persuasive Essay About Smoking

Here are a few tips and tricks to make your persuasive essay about smoking stand out:

1. Do Your Research

Before you start writing, make sure to do thorough research on the topic of smoking and its effects.

Look for primary and secondary sources that provide valuable information about the issue.

2. Create an Outline

An outline is essential when organizing your thoughts and ideas into a cohesive structure. This can help you organize your arguments and counterarguments.

Read our blog about creating a persuasive essay outline to master your next essay.

Check out this amazing video here!

3. Clearly Define the Issue

Make sure your writing identifies the problem of smoking and why it should be stopped.

4. Highlight Consequences

Show readers the possible negative impacts of smoking, like cancer, respiratory issues, and addiction.

5. Identity Solutions

Provide viable solutions to the problem, such as cessation programs, cigarette alternatives, and lifestyle changes.

6. Be Research-Oriented

Research facts about smoking and provide sources for those facts that can be used to support your argument.

7. Aim For the Emotions

Use powerful language and vivid imagery to draw readers in and make them feel like you do about smoking.

8. Use Personal Stories

Share personal stories or anecdotes of people who have successfully quit smoking and those negatively impacted by it.

9. Include an Action Plan

Offer step-by-step instructions on how to quit smoking, and provide resources for assistance effectively.

10. Reference Experts

Incorporate quotes and opinions from medical professionals, researchers, or other experts in the field.

These tips can help you write an effective persuasive essay about smoking and its negative effects on the body, mind, and society.

When your next writing assignment has you feeling stuck, don't forget that essay examples about smoking are always available to break through writer's block.

And if you need help getting started, our expert essay writer at CollegeEssay.org is more than happy to assist.

Just give us your details, and our persuasive essay writer will start working on crafting a masterpiece.

We provide top-notch essay writing service online to help you get the grades you deserve and boost your career.

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Frequently Asked Questions

What would be a good thesis statement for smoking.

A good thesis statement for smoking could be: "Smoking has serious health risks that outweigh any perceived benefits, and its use should be strongly discouraged."

What are good topics for persuasive essays?

Good topics for persuasive essays include the effects of smoking on health, the dangers of second-hand smoke, the economic implications of tobacco taxes, and ways to reduce teenage smoking.

These topics can be explored differently to provide a unique and engaging argument.

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Report: China is fueling US fentanyl crisis by subsidizing production

Posted: April 17, 2024 | Last updated: April 17, 2024

China 's leaders give tax breaks to companies that produce fentanyl chemicals and cause some 80,000 US overdose deaths each year, a damning House report warns. Beijing is fueling America's fentanyl crisis by subsidizing the manufacture of materials used by traffickers to make pills outside the country, say papers from a committee on China. Researchers accessed a government website that revealed tax rebates for the production of specific fentanyl precursors and other synthetics — as long as those companies sell them outside of China.

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AI Index Report

Welcome to the seventh edition of the AI Index report. The 2024 Index is our most comprehensive to date and arrives at an important moment when AI’s influence on society has never been more pronounced. This year, we have broadened our scope to more extensively cover essential trends such as technical advancements in AI, public perceptions of the technology, and the geopolitical dynamics surrounding its development. Featuring more original data than ever before, this edition introduces new estimates on AI training costs, detailed analyses of the responsible AI landscape, and an entirely new chapter dedicated to AI’s impact on science and medicine.

Read the 2024 AI Index Report

The AI Index report tracks, collates, distills, and visualizes data related to artificial intelligence (AI). Our mission is to provide unbiased, rigorously vetted, broadly sourced data in order for policymakers, researchers, executives, journalists, and the general public to develop a more thorough and nuanced understanding of the complex field of AI.

The AI Index is recognized globally as one of the most credible and authoritative sources for data and insights on artificial intelligence. Previous editions have been cited in major newspapers, including the The New York Times, Bloomberg, and The Guardian, have amassed hundreds of academic citations, and been referenced by high-level policymakers in the United States, the United Kingdom, and the European Union, among other places. This year’s edition surpasses all previous ones in size, scale, and scope, reflecting the growing significance that AI is coming to hold in all of our lives.

Steering Committee Co-Directors

Ray Perrault

Steering committee members.

Erik Brynjolfsson

John Etchemendy

Katrina Ligett

Terah Lyons

James Manyika

Juan Carlos Niebles

Vanessa Parli

Yoav Shoham

Russell Wald

Staff members.

Loredana Fattorini

Nestor Maslej

Letter from the co-directors.

A decade ago, the best AI systems in the world were unable to classify objects in images at a human level. AI struggled with language comprehension and could not solve math problems. Today, AI systems routinely exceed human performance on standard benchmarks.

Progress accelerated in 2023. New state-of-the-art systems like GPT-4, Gemini, and Claude 3 are impressively multimodal: They can generate fluent text in dozens of languages, process audio, and even explain memes. As AI has improved, it has increasingly forced its way into our lives. Companies are racing to build AI-based products, and AI is increasingly being used by the general public. But current AI technology still has significant problems. It cannot reliably deal with facts, perform complex reasoning, or explain its conclusions.

AI faces two interrelated futures. First, technology continues to improve and is increasingly used, having major consequences for productivity and employment. It can be put to both good and bad uses. In the second future, the adoption of AI is constrained by the limitations of the technology. Regardless of which future unfolds, governments are increasingly concerned. They are stepping in to encourage the upside, such as funding university R&D and incentivizing private investment. Governments are also aiming to manage the potential downsides, such as impacts on employment, privacy concerns, misinformation, and intellectual property rights.

As AI rapidly evolves, the AI Index aims to help the AI community, policymakers, business leaders, journalists, and the general public navigate this complex landscape. It provides ongoing, objective snapshots tracking several key areas: technical progress in AI capabilities, the community and investments driving AI development and deployment, public opinion on current and potential future impacts, and policy measures taken to stimulate AI innovation while managing its risks and challenges. By comprehensively monitoring the AI ecosystem, the Index serves as an important resource for understanding this transformative technological force.

On the technical front, this year’s AI Index reports that the number of new large language models released worldwide in 2023 doubled over the previous year. Two-thirds were open-source, but the highest-performing models came from industry players with closed systems. Gemini Ultra became the first LLM to reach human-level performance on the Massive Multitask Language Understanding (MMLU) benchmark; performance on the benchmark has improved by 15 percentage points since last year. Additionally, GPT-4 achieved an impressive 0.97 mean win rate score on the comprehensive Holistic Evaluation of Language Models (HELM) benchmark, which includes MMLU among other evaluations.

Although global private investment in AI decreased for the second consecutive year, investment in generative AI skyrocketed. More Fortune 500 earnings calls mentioned AI than ever before, and new studies show that AI tangibly boosts worker productivity. On the policymaking front, global mentions of AI in legislative proceedings have never been higher. U.S. regulators passed more AI-related regulations in 2023 than ever before. Still, many expressed concerns about AI’s ability to generate deepfakes and impact elections. The public became more aware of AI, and studies suggest that they responded with nervousness.

Ray Perrault Co-director, AI Index

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State of Creativity Report 2024

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Adobe, in partnership with Edelman Data & Intelligence and Havas Play, has created this report to explore the state of creativity and the opportunities generative AI offers to improve productivity and creativity.

It’s no secret that the world of work is speeding up, and the creative world is no exception. This report explores the state of creative productivity across various industries, including retail, media, finance, and manufacturing. We’ll uncover the increased volume of work that both creative and non-creative roles are currently facing, as well as the pressure to deliver work faster, and the strains this puts on decision-makers.

Whether you’re looking to improve productivity, ease the strain on employees, or take your creativity to the next level, this report is packed full of real-world insights to help you, no matter what stage of the journey you are at.

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Smoking: Causes and Effects Essay

Among numerous bad habits of modern society smoking seems to be of the greatest importance. Not only does it affect the person who smokes, but also those who are around him. Many people argue about the appropriate definition of smoking, whether it is a disease or just a bad habit. Considering the peculiarities of a habit and of a disease, smoking can be considered as a habit rather than a disease. Among signifiers of a bad habit, it should be pointed out that a bad habit can be controlled by willpower, it can be prevented, and it can be cured (Gilman and Zun 33). Smoking can be fought against with the help of all the points mentioned above. Thus, it is a bad habit which can be easily refused if an individual possessing it has a strong decision to quit. Moreover, it can be cured in many different ways, and it can be prevented by education and other social norms.

Considering the first element, which one of the most important out of the three, willpower is a key to get rid of such a bad habit as smoking, which is very difficult to give up. If a person has a strong determination to quit smoking, he will have to endure considerably a short period of time of physical discomfort. One of the most important part of quitting, is that that is doesn’t require medical help, that is to say, a person is not likely to suffer a procedure that is risky to health and life. In comparison to alcoholism or drug addiction, where medical help is essential to save life of a person who needs a certain amount of an alcohol or drug substance in has blood to survive, the lack of nicotine in blood produces just a physical discomfort that is not dangerous for health and can be handled with the help of willpower. Regarding the second aspect of a bad habit, prevention, smoking can be prevented in early childhood with the help of proper education and social norms (Brinkman et al 689). Many people start smoking when they are teenagers just to prove they are adults in companies. If the society was able to produce a negative impression of this bad habit, so that it doesn’t seem to be sign of being an adult, it would be easier to prevent many children from smoking (Albaum et al 11).

The last aspect of a bad habit is a cure for it. Smoking can be cured in many different ways. There are many different techniques, starting from a nicotine plaster and ending with special clinics and communities helping people to get rid of this problem. If a person wants to quit, he or she has various options to help him or her to solve this problem. To conclude, smoking is a bad habit that can be easily quitted. Although there is an addiction to smoking, the lack of nicotine is not dangerous to the life of a smoker and can be handled without medical intervention. The most important aspect of this bad habit, which actually makes a habit, is that it can be quitted with the help of willpower. Moreover, it can be prevented with alteration of attitude towards smoking and it can be cured in many different ways (Albaum et al 23).

Despite widespread public awareness of the multiple health risks associated with smoking, one out of every four girls under age 18 is a smoker and more than 25 million American women smoke. Whereas the last two decades have seen an overall decrease in smoking prevalence, the rate of smoking has declined much more slowly among women than among men. If current trends continue, smoking rates of women will overtake those of men by the year 2000. Smoking rates are highest, approaching 30%, among women of reproductive age (18–44 years). Rates of smoking are particularly high among young White women with a high school education or less and low income. Cessation rates are lower among African American women (30% have quit) compared to White women (43% have quit). Minority and young women who have low rates of self-initiated cessation are also underrepresented in formal smoking cessation programs (Gilman and Zun 87). A greater proportion of women than men are pre-contemplators, that is, not considering quitting smoking within 6 months and have lower self-confidence that they could quit if they were to try. The debate continues regarding whether or not women are less likely to be successful at quitting when they try than men, with some evidence suggesting that women are more likely than men to relapse and others indicating no gender differences). Regardless, rates of relapse are very high, both among self-quitters and those who participate in formal cessation programs (Albaum et al 24).

Interventions specifically designed for smokers have attempted to address the role of weight concerns as an inhibitor to cessation and long-term maintenance. A randomized trial tested nicotine gum or a behavioral weight control program each alone, or in combination as adjuncts to an intensive group cessation intervention for weight concerned women smokers. The intervention integrated accepted cognitive and behavioral coping strategies for quitting smoking, changing eating behaviors, and developing a walking program.

Works Cited

Albaum, G., Baker, K.G., Hozier, G.C., Rogers, R.D. Smoking Behavior, Information Sources, and Consumption Values of Teenagers: Implications for Public Policy and Other Intervention Failures. Journal of Consumer Affairs , 36 (1), 2002: 5-55.

Brinkman, M.C., Callahan, P.J., Gordon, S.M., Kenny, D.V., Wallace, L.A. Volatile Organic Compounds as Breath Biomarkers for Active and Passive Smoking. Environmental Health Perspectives, 110 (7), 2002, p. 689.

Gilman Sander L. and Xhou Zun. Smoke: A GlobalHistory of Smoking. Reaktion Books; illustrated edition edition, 2004.

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NPR in Turmoil After It Is Accused of Liberal Bias

An essay from an editor at the broadcaster has generated a firestorm of criticism about the network on social media, especially among conservatives.

Uri Berliner, wearing a dark zipped sweater over a white T-shirt, sits in a darkened room, a big plant and a yellow sofa behind him.

By Benjamin Mullin and Katie Robertson

NPR is facing both internal tumult and a fusillade of attacks by prominent conservatives this week after a senior editor publicly claimed the broadcaster had allowed liberal bias to affect its coverage, risking its trust with audiences.

Uri Berliner, a senior business editor who has worked at NPR for 25 years, wrote in an essay published Tuesday by The Free Press, a popular Substack publication, that “people at every level of NPR have comfortably coalesced around the progressive worldview.”

Mr. Berliner, a Peabody Award-winning journalist, castigated NPR for what he said was a litany of journalistic missteps around coverage of several major news events, including the origins of Covid-19 and the war in Gaza. He also said the internal culture at NPR had placed race and identity as “paramount in nearly every aspect of the workplace.”

Mr. Berliner’s essay has ignited a firestorm of criticism of NPR on social media, especially among conservatives who have long accused the network of political bias in its reporting. Former President Donald J. Trump took to his social media platform, Truth Social, to argue that NPR’s government funding should be rescinded, an argument he has made in the past.

NPR has forcefully pushed back on Mr. Berliner’s accusations and the criticism.

“We’re proud to stand behind the exceptional work that our desks and shows do to cover a wide range of challenging stories,” Edith Chapin, the organization’s editor in chief, said in an email to staff on Tuesday. “We believe that inclusion — among our staff, with our sourcing, and in our overall coverage — is critical to telling the nuanced stories of this country and our world.” Some other NPR journalists also criticized the essay publicly, including Eric Deggans, its TV critic, who faulted Mr. Berliner for not giving NPR an opportunity to comment on the piece.

In an interview on Thursday, Mr. Berliner expressed no regrets about publishing the essay, saying he loved NPR and hoped to make it better by airing criticisms that have gone unheeded by leaders for years. He called NPR a “national trust” that people rely on for fair reporting and superb storytelling.

“I decided to go out and publish it in hopes that something would change, and that we get a broader conversation going about how the news is covered,” Mr. Berliner said.

He said he had not been disciplined by managers, though he said he had received a note from his supervisor reminding him that NPR requires employees to clear speaking appearances and media requests with standards and media relations. He said he didn’t run his remarks to The New York Times by network spokespeople.

When the hosts of NPR’s biggest shows, including “Morning Edition” and “All Things Considered,” convened on Wednesday afternoon for a long-scheduled meet-and-greet with the network’s new chief executive, Katherine Maher , conversation soon turned to Mr. Berliner’s essay, according to two people with knowledge of the meeting. During the lunch, Ms. Chapin told the hosts that she didn’t want Mr. Berliner to become a “martyr,” the people said.

Mr. Berliner’s essay also sent critical Slack messages whizzing through some of the same employee affinity groups focused on racial and sexual identity that he cited in his essay. In one group, several staff members disputed Mr. Berliner’s points about a lack of ideological diversity and said efforts to recruit more people of color would make NPR’s journalism better.

On Wednesday, staff members from “Morning Edition” convened to discuss the fallout from Mr. Berliner’s essay. During the meeting, an NPR producer took issue with Mr. Berliner’s argument for why NPR’s listenership has fallen off, describing a variety of factors that have contributed to the change.

Mr. Berliner’s remarks prompted vehement pushback from several news executives. Tony Cavin, NPR’s managing editor of standards and practices, said in an interview that he rejected all of Mr. Berliner’s claims of unfairness, adding that his remarks would probably make it harder for NPR journalists to do their jobs.

“The next time one of our people calls up a Republican congressman or something and tries to get an answer from them, they may well say, ‘Oh, I read these stories, you guys aren’t fair, so I’m not going to talk to you,’” Mr. Cavin said.

Some journalists have defended Mr. Berliner’s essay. Jeffrey A. Dvorkin, NPR’s former ombudsman, said Mr. Berliner was “not wrong” on social media. Chuck Holmes, a former managing editor at NPR, called Mr. Berliner’s essay “brave” on Facebook.

Mr. Berliner’s criticism was the latest salvo within NPR, which is no stranger to internal division. In October, Mr. Berliner took part in a lengthy debate over whether NPR should defer to language proposed by the Arab and Middle Eastern Journalists Association while covering the conflict in Gaza.

“We don’t need to rely on an advocacy group’s guidance,” Mr. Berliner wrote, according to a copy of the email exchange viewed by The Times. “Our job is to seek out the facts and report them.” The debate didn’t change NPR’s language guidance, which is made by editors who weren’t part of the discussion. And in a statement on Thursday, the Arab and Middle Eastern Journalists Association said it is a professional association for journalists, not a political advocacy group.

Mr. Berliner’s public criticism has highlighted broader concerns within NPR about the public broadcaster’s mission amid continued financial struggles. Last year, NPR cut 10 percent of its staff and canceled four podcasts, including the popular “Invisibilia,” as it tried to make up for a $30 million budget shortfall. Listeners have drifted away from traditional radio to podcasts, and the advertising market has been unsteady.

In his essay, Mr. Berliner laid some of the blame at the feet of NPR’s former chief executive, John Lansing, who said he was retiring at the end of last year after four years in the role. He was replaced by Ms. Maher, who started on March 25.

During a meeting with employees in her first week, Ms. Maher was asked what she thought about decisions to give a platform to political figures like Ronna McDaniel, the former Republican Party chair whose position as a political analyst at NBC News became untenable after an on-air revolt from hosts who criticized her efforts to undermine the 2020 election.

“I think that this conversation has been one that does not have an easy answer,” Ms. Maher responded.

Benjamin Mullin reports on the major companies behind news and entertainment. Contact Ben securely on Signal at +1 530-961-3223 or email at [email protected] . More about Benjamin Mullin

Katie Robertson covers the media industry for The Times. Email: [email protected] More about Katie Robertson

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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 ]

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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.
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NPR suspends veteran editor as it grapples with his public criticism

David Folkenflik

NPR suspended senior editor Uri Berliner for five days without pay after he wrote an essay accusing the network of losing the public's trust and appeared on a podcast to explain his argument. Uri Berliner hide caption

NPR suspended senior editor Uri Berliner for five days without pay after he wrote an essay accusing the network of losing the public's trust and appeared on a podcast to explain his argument.

NPR has formally punished Uri Berliner, the senior editor who publicly argued a week ago that the network had "lost America's trust" by approaching news stories with a rigidly progressive mindset.

Berliner's five-day suspension without pay, which began last Friday, has not been previously reported.

Yet the public radio network is grappling in other ways with the fallout from Berliner's essay for the online news site The Free Press . It angered many of his colleagues, led NPR leaders to announce monthly internal reviews of the network's coverage, and gave fresh ammunition to conservative and partisan Republican critics of NPR, including former President Donald Trump.

Conservative activist Christopher Rufo is among those now targeting NPR's new chief executive, Katherine Maher, for messages she posted to social media years before joining the network. Among others, those posts include a 2020 tweet that called Trump racist and another that appeared to minimize rioting during social justice protests that year. Maher took the job at NPR last month — her first at a news organization .

In a statement Monday about the messages she had posted, Maher praised the integrity of NPR's journalists and underscored the independence of their reporting.

"In America everyone is entitled to free speech as a private citizen," she said. "What matters is NPR's work and my commitment as its CEO: public service, editorial independence, and the mission to serve all of the American public. NPR is independent, beholden to no party, and without commercial interests."

The network noted that "the CEO is not involved in editorial decisions."

In an interview with me later on Monday, Berliner said the social media posts demonstrated Maher was all but incapable of being the person best poised to direct the organization.

"We're looking for a leader right now who's going to be unifying and bring more people into the tent and have a broader perspective on, sort of, what America is all about," Berliner said. "And this seems to be the opposite of that."

Conservative critics of NPR are now targeting its new chief executive, Katherine Maher, for messages she posted to social media years before joining the public radio network last month. Stephen Voss/Stephen Voss hide caption

Conservative critics of NPR are now targeting its new chief executive, Katherine Maher, for messages she posted to social media years before joining the public radio network last month.

He said that he tried repeatedly to make his concerns over NPR's coverage known to news leaders and to Maher's predecessor as chief executive before publishing his essay.

Berliner has singled out coverage of several issues dominating the 2020s for criticism, including trans rights, the Israel-Hamas war and COVID. Berliner says he sees the same problems at other news organizations, but argues NPR, as a mission-driven institution, has a greater obligation to fairness.

"I love NPR and feel it's a national trust," Berliner says. "We have great journalists here. If they shed their opinions and did the great journalism they're capable of, this would be a much more interesting and fulfilling organization for our listeners."

A "final warning"

The circumstances surrounding the interview were singular.

Berliner provided me with a copy of the formal rebuke to review. NPR did not confirm or comment upon his suspension for this article.

In presenting Berliner's suspension Thursday afternoon, the organization told the editor he had failed to secure its approval for outside work for other news outlets, as is required of NPR journalists. It called the letter a "final warning," saying Berliner would be fired if he violated NPR's policy again. Berliner is a dues-paying member of NPR's newsroom union but says he is not appealing the punishment.

The Free Press is a site that has become a haven for journalists who believe that mainstream media outlets have become too liberal. In addition to his essay, Berliner appeared in an episode of its podcast Honestly with Bari Weiss.

A few hours after the essay appeared online, NPR chief business editor Pallavi Gogoi reminded Berliner of the requirement that he secure approval before appearing in outside press, according to a copy of the note provided by Berliner.

In its formal rebuke, NPR did not cite Berliner's appearance on Chris Cuomo's NewsNation program last Tuesday night, for which NPR gave him the green light. (NPR's chief communications officer told Berliner to focus on his own experience and not share proprietary information.) The NPR letter also did not cite his remarks to The New York Times , which ran its article mid-afternoon Thursday, shortly before the reprimand was sent. Berliner says he did not seek approval before talking with the Times .

NPR defends its journalism after senior editor says it has lost the public's trust

Berliner says he did not get permission from NPR to speak with me for this story but that he was not worried about the consequences: "Talking to an NPR journalist and being fired for that would be extraordinary, I think."

Berliner is a member of NPR's business desk, as am I, and he has helped to edit many of my stories. He had no involvement in the preparation of this article and did not see it before it was posted publicly.

In rebuking Berliner, NPR said he had also publicly released proprietary information about audience demographics, which it considers confidential. He said those figures "were essentially marketing material. If they had been really good, they probably would have distributed them and sent them out to the world."

Feelings of anger and betrayal inside the newsroom

His essay and subsequent public remarks stirred deep anger and dismay within NPR. Colleagues contend Berliner cherry-picked examples to fit his arguments and challenge the accuracy of his accounts. They also note he did not seek comment from the journalists involved in the work he cited.

Morning Edition host Michel Martin told me some colleagues at the network share Berliner's concerns that coverage is frequently presented through an ideological or idealistic prism that can alienate listeners.

"The way to address that is through training and mentorship," says Martin, herself a veteran of nearly two decades at the network who has also reported for The Wall Street Journal and ABC News. "It's not by blowing the place up, by trashing your colleagues, in full view of people who don't really care about it anyway."

Several NPR journalists told me they are no longer willing to work with Berliner as they no longer have confidence that he will keep private their internal musings about stories as they work through coverage.

"Newsrooms run on trust," NPR political correspondent Danielle Kurtzleben tweeted last week, without mentioning Berliner by name. "If you violate everyone's trust by going to another outlet and sh--ing on your colleagues (while doing a bad job journalistically, for that matter), I don't know how you do your job now."

Berliner rejected that critique, saying nothing in his essay or subsequent remarks betrayed private observations or arguments about coverage.

Other newsrooms are also grappling with questions over news judgment and confidentiality. On Monday, New York Times Executive Editor Joseph Kahn announced to his staff that the newspaper's inquiry into who leaked internal dissent over a planned episode of its podcast The Daily to another news outlet proved inconclusive. The episode was to focus on a December report on the use of sexual assault as part of the Hamas attack on Israel in October. Audio staffers aired doubts over how well the reporting stood up to scrutiny.

"We work together with trust and collegiality everyday on everything we produce, and I have every expectation that this incident will prove to be a singular exception to an important rule," Kahn wrote to Times staffers.

At NPR, some of Berliner's colleagues have weighed in online against his claim that the network has focused on diversifying its workforce without a concomitant commitment to diversity of viewpoint. Recently retired Chief Executive John Lansing has referred to this pursuit of diversity within NPR's workforce as its " North Star ," a moral imperative and chief business strategy.

In his essay, Berliner tagged the strategy as a failure, citing the drop in NPR's broadcast audiences and its struggle to attract more Black and Latino listeners in particular.

"During most of my tenure here, an open-minded, curious culture prevailed. We were nerdy, but not knee-jerk, activist, or scolding," Berliner writes. "In recent years, however, that has changed."

Berliner writes, "For NPR, which purports to consider all things, it's devastating both for its journalism and its business model."

NPR investigative reporter Chiara Eisner wrote in a comment for this story: "Minorities do not all think the same and do not report the same. Good reporters and editors should know that by now. It's embarrassing to me as a reporter at NPR that a senior editor here missed that point in 2024."

Some colleagues drafted a letter to Maher and NPR's chief news executive, Edith Chapin, seeking greater clarity on NPR's standards for its coverage and the behavior of its journalists — clearly pointed at Berliner.

A plan for "healthy discussion"

On Friday, CEO Maher stood up for the network's mission and the journalism, taking issue with Berliner's critique, though never mentioning him by name. Among her chief issues, she said Berliner's essay offered "a criticism of our people on the basis of who we are."

Berliner took great exception to that, saying she had denigrated him. He said that he supported diversifying NPR's workforce to look more like the U.S. population at large. She did not address that in a subsequent private exchange he shared with me for this story. (An NPR spokesperson declined further comment.)

Late Monday afternoon, Chapin announced to the newsroom that Executive Editor Eva Rodriguez would lead monthly meetings to review coverage.

"Among the questions we'll ask of ourselves each month: Did we capture the diversity of this country — racial, ethnic, religious, economic, political geographic, etc — in all of its complexity and in a way that helped listeners and readers recognize themselves and their communities?" Chapin wrote in the memo. "Did we offer coverage that helped them understand — even if just a bit better — those neighbors with whom they share little in common?"

Berliner said he welcomed the announcement but would withhold judgment until those meetings played out.

In a text for this story, Chapin said such sessions had been discussed since Lansing unified the news and programming divisions under her acting leadership last year.

"Now seemed [the] time to deliver if we were going to do it," Chapin said. "Healthy discussion is something we need more of."

Disclosure: This story was reported and written by NPR Media Correspondent David Folkenflik and edited by Deputy Business Editor Emily Kopp and Managing Editor Gerry Holmes. Under NPR's protocol for reporting on itself, no NPR corporate official or news executive reviewed this story before it was posted publicly.

Katherine Maher
uri berliner

Michigan, Ohio brace for storms after tornadoes rip through Iowa, Kansas, Missouri

Detroit, Cleveland and Cincinnati are in the bull's-eye Wednesday.

As Iowa, Kansas, Missouri and Nebraska clean up from the 14 confirmed tornadoes that ripped through the region, the tornado threat moves east on Wednesday to Michigan and Ohio.

The strongest tornado so far was an EF-2 with 118 mph winds in Greenwood County, Kansas.

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Haitian migrant double homicide suspect used biden cbp one app to legally enter us: report.

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A Haitian migrant who allegedly killed two of his roommates in New York used the Biden administration’s signature CBP One program to legally enter the country, according to Fox News .

Kenol Baptiste is accused of second-degree murder, first-degree manslaughter and fourth-degree criminal possession of a weapon in Middletown, New York.

The Haitian national entered the US on July 25 of last year after making an appointment through the CBP One app which allows migrants to pre-arrange travel to the US and be pre-screened, then enter the country, collect paperwork and stay and work for up to two years.

Mugshot of Middletown murder suspect Kenol Baptiste

The two victims, one of whom died at the scene and the other in a subsequent surgery, had multiple stab wounds. The identities of the victims have not been made public.

Police were able to locate Baptiste in the nearby woods and he is currently being held at the Orange County Jail. Immigration and Customs Enforcement (ICE) has asked local authorities to take Baptiste into federal custody once he has answered state charges.

Orange County Executive Steven Neuhaus told Fox News the two victims were also Haitian, adding that seven people were living in the single apartment.

“He came in over the border, but they did give him working papers, and he was scheduled to get an asylum hearing by a federal judge,” Neuhaus told Fox News.

The charges against Baptiste bring into question how effectively migrants are being screened upon arrival and how reliable the information they submit to the governement before being allowed into the US is.

Republicans from the House Homeland Security Committee got data from Homeland Security last year which found that over 95% of all CBP One applicants are granted entry to the US .

Middletown murder suspect, Kenol Baptiste, is accused of fatally stabbing his roommates.

The Biden administration expanded the use of the CBP One app in January to allow 547,000 migrants into the country per year, 1450 people per day.

The app also allows migrants from Cuba, Haiti, Nicaragua and Venezuela to facilitate their travel via commercial flights to the US in a separate parole program, which has allowed roughly 404,000 entries through March.

Migrants taking the flights must have sponsors in the US, where they are permitted to stay for a period of up to two years.

One migrant known to have taken a parole flight using CBP One is Haitian national Cory Alvarez , 26, who has since been arrested in Rockland, Massachusetts, and accused of raping a disabled 15-year-old girl.

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