Friday, 10 March 2017

How well do smoking cessation programs work?

After all we have learned about smoking since the 1950s, why have we still not conquered the tobacco epidemic? The tobacco epidemic is persistent. From 2000 to 2014, the percentage of former smokers in the Canadian population changed not at all, staying at 37% (Statistics Canada, 2016). New quitters only just replace the proportion of those who relapse or die. The tobacco industry has long known how few smokers quit, which is why it seldom opposes smoking cessation programming. According to tobacco industry monitoring data, from 1971 to 1991, people who managed to stay quit for one year as a percentage of ever-smokers was almost always in the very narrow range of 1–2% per year. The lowest value was 0.4% in 1983 and the highest was 2.2% in 1976 (Imperial Tobacco Ltd., 1991). More recent, but similar low rates of quitting in Ontario were reported by the Ontario Tobacco Research Unit (OTRU; 2016). During the period 2007–2014, annualized quit rates were reported to be in the range of 1.3–2.2%.

Still, people do successfully quit, eventually. It may take them many tries, but many are successful. By 2014, there were about twice as many former smokers as current smokers in Canada (Statistics Canada, 2016).

How do people quit? Most successful quitters do so on their own. In Ontario in 2014, only 1.7% of smokers succeeded in quitting for a full year, and most of these quit on their own.  About two-thirds of those successful quitters did not use any of the ten cessation services evaluated by OTRU (OTRU; 2016). Currently, about two-thirds to three-quarters of Americans who quit do so on their own (Chapman. & Mackenzie, 2010). Looking back in time, the figures are even higher. In 1986, it was estimated that over 90% of Americans who had quit smoking up to that point in time had done so on their own American Cancer Society. (1986)In earlier years, less assistance for smoking cessation was available.  Most people quit on their own.

But what of the others, those who do seek assistance for smoking cessation? How successful are they? Nicotine replacement therapy (NRT) is a popular form of providing smoking cessation assistance and a Cochrane review of over 130 studies found that NRT achieved a success rate that was 50–70% greater than that achieved with placebo (Stead et al.,2012). However, there are sound reasons to believe that this apparent success is not maintained when the therapy moves from the research environment to the real world. John Pierce and his colleagues reported that after three or more months of follow-up, Americans who quit smoking on their own had slightly higher success rates than those who used NRT or some other form of assistance. Among heavy smokers, the NRT three-month success rates was 9%, compared with 15% among those who quit unassisted (Pierce et al., 2012).

Cessation programs have neither broad reach nor outstanding success rates. The Ontario government provides support to 10 different smoking cessation programs. These programs all use well-established forms of assistance of proven worth. They range from minimal interventions like helplines to intensive system-wide interventions in health care settings. Their reach and effectiveness were carefully evaluated. Collectively they reached 139,000 people—about 7% of all Ontario smokers. Of these, it was estimated that about 12,000 actually quit smoking, which amounts to only about 0.6% of all smokers in Ontario (OTRU, 2016). Ten government-supported forms of smoking cessation assistance yielded a barely perceptible increase in the number of people in Ontario who successfully quit smoking.  Recently, the Ontario government announced that it will increase in spending on smoking cessation programming by $5 million per year.

The picture seems bleak. Smoking cessation rates are low. Few people use assistance, and assistance is not very helpful.

Years of experience with tobacco control has taught us that comprehensive tobacco control programs work best and that no comprehensive tobacco control program will be credible unless it includes smoking cessation programming. Even if success rates are low, some people are helped by receiving assistance in quitting smoking. Some will succeed in quitting smoking with one or another of these strategies in one or another of these settings. For others, assisted smoking cessation will be a first step or an intermediate step in a longer journey toward quitting. A single attempt to quit smoking should not be viewed as a success or a failure, but as a rehearsal in which something is learned. There may be several more rehearsals before opening night.

Another important reason to ensure smoking cessation services are widely available in clinical settings is because of the moral and legal reasons to do so. Smoking cessation service do achieve success, albeit modest success. Failure to treat tobacco addiction should be viewed as a serious lapse of professional practice, not unlike failure to monitor and treat high blood pressure or diabetes.
Smoking cessation practitioners will often feel that they are swimming upstream against an unceasing strong current. They are. One element of this strong countercurrent is the drug itself. A far more important element of the strong countercurrent is the tobacco industry. Big Tobacco can and does maintain and even increase the attractiveness and addictiveness of cigarettes and other tobacco products. Despite controls that have been placed on the tobacco industry in recent decades, Big Tobacco continues to stimulate demand for its products. It successfully sells over 5 trillion cigarettes per year worldwide to more than 1 billion smokers, and earns over US$20 billion in profits by doing so. A few smoking cessation practitioners here and there are no match for this global drug-pushing machine.

Or are they? Smoking cessation practitioners can stay in their clinics, continue to treat patients and enjoy only a modest rate of success. If that is all they do, the relentless ground war of attrition against Big Tobacco will continue, with neither side clearly gaining the upper hand. So here is a challenge. In addition to their clinical work, smoking-cessation practitioners are invited to become advocates for a tobacco-free future. Phasing out tobacco is possible. Smoking cessation practitioners, by becoming strong and effective advocates for a tobacco-free future, can help make it happen.


American Cancer Society. (1986). Cancer facts and figures. Atlanta, GA:
Statistics Canada. (2016). Canadian Community Health Survey. Public use microdata file. Cycles 1–7. Unpublished tabulations.
Statistics Canada. (2016). Canadian Community Health Survey. Public use microdata file. Cycle 7. Unpublished tabulations.