Smoking kills. Everyone knows it (or should know it). And yet an estimated 45.3 million people in the United States still smoke cigarettes, according to data published by the Centers for Disease Control and Prevention (CDC).1 This means roughly 19% of the population is at risk for smoking-related ailments, such as lung cancer and emphysema, and at greater risk for more common conditions, like heart disease and stroke. Smoking is the leading cause of preventable death in the United States, accounting for approximately 443,000 deaths, or one of every five, each year, says the CDC.1

So it may not be surprising that 68.8% of US adult smokers want to quit the habit1 (in fact, it may be surprising that the figure isn’t higher). But quitting isn’t easy. CDC data covering 2001 through 2010 note that 52.4% of smokers had made a quit attempt in the past year, but only 6.2% had successfully maintained smoking cessation.

The good news is that people continue to try to quit, and the number of former smokers has exceeded the number of current smokers since 2002.1 The majority of smokers achieve this on their own.

“Our analysis of the 2002-2003 Tobacco Use Supplement of the Current Population Surveys indicated that 63% of smokers who attempted to quit did so without using nicotine replacement therapy, prescription medication, quitlines, clinics, or any other organized help. Therefore, most smokers still try to quit on their own. And they tend to be more successful than those who use quitting aids,” says Sharon Cummins, PhD, director of research and evaluation for the California Smokers’ Helpline, and assistant professor in the Department of Family and Preventive Medicine at the University of California (UC), San Diego.

This is not an indictment of quitting aids, however. “It is because the choice to use quitting aids is based on self-selection. Those who use quitting aids are those who think they will be useful. These smokers may have tried to quit on their own and been unsuccessful,” Cummins says.

In fact, the programs generally have been shown to be helpful to the individuals who use them. Pharmaceutical aids have been found to increase success by 50%.2 “If smokers call a quitline and are randomly assigned to counseling or self-help materials with no counseling, those assigned to counseling will do better, on average. The same is true if you compare the nicotine patch to a placebo patch or any of the other cessation aids,” Cummins says.

So why has the proportion of smokers with successful quit efforts decreased? Researchers at the UC San Diego Moores Cancer Center, including Cummins, reviewed the data on smoking cessation covering the past 20 years to examine why the programs have not made a change in the population of smokers and whether public policy plays a role. Theories explored the impact of pharmaceutical marketing strategies, and the work was published in the April issue of the Annual Review of Public Health.2

Part of the problem is simply reach. “If you have a very efficacious program but very few people use it, then you wouldn’t expect to find a huge impact on the population in general,” Cummins says, noting only about 1% to 2% of smokers use telephone-based quitlines.

A second issue is the problem of a “hardening target.” “As more smokers try to quit, the ones who have an easier time will be successful and, consequently, leave a pool of smokers who have a harder time—perhaps because they are more addicted or have fewer emotional and financial resources to cope with quitting. Over time, this process leads to a population of smokers that is harder to help,” Cummins says.

Another part of the problem may be marketing of cessation aids and public policy regarding smoking cessation. In some instances, policies actively discourage unassisted smoking cessation, despite the fact that unassisted efforts have been shown to be very successful.

Cummins cites an example in Europe, where the government gave everyone access to smoking quit aids through the national health service but saw no change in the overall population cessation rate. “We’re not sure why. But it shows that putting a policy in place, even with the best of intentions, can have unexpected consequences,” Cummins says.

Aiding Quitting, Abetting Nicotine

Who will best benefit from the use of a smoking cessation aid? “Anybody who thinks they’re going to get benefit from these products,” says Sharon Cummins, PhD, director of research and evaluation for the California Smokers’ Helpline, and assistant professor in the Department of Family and Preventive Medicine at the University of California, San Diego.

However, those with a heavier physical addiction or greater psychological habit may benefit more. There are a number of different mechanisms by which the various methods work, and the choice is individual. One has not been proven better than another, but the Centers for Disease Control and Prevention (CDC) has identified a number of cessation aids proven effective for smokers who want to quit. These include1:

  • Brief clinical interventions, whereby a physician takes 10 minutes or less to deliver advice and assistance regarding quitting;
  • Counseling, whether individual, group, or telephone-based;
  • Behavioral cessation therapies, such as training in problem-solving; and
  • More intensive treatments, with more time spent with counselors, for example.

Some medications also have been found to be helpful:

  • Nicotine replacement therapies help to lessen physical withdrawal symptoms so the smoker can focus on altering behavior. “Then, eventually, as they get through life without smoking, they start to taper off on the amount of nicotine. So it allows the quitting smoker to focus on one aspect of the problem at a time,” Cummins says. Options include nicotine patches, nicotine lozenges, and nicotine gum.
  • Non-nicotine medications produce the same effect through direct action in the brain. Zyban (bupropion), which is also an antidepressant, works with neurotransmitters in the dopamine system, in particular, to mitigate withdrawal symptoms and mood changes; Chantix (varenicline) satiates nicotine receptors within the body so smoking itself is not as pleasurable, causing the craving to lessen.

In general, a combination of medication and counseling is more effective for smoking cessation than either is alone,1 but both help to do away with excuses that can prevent smokers from successfully quitting.

  1. Centers for Disease Control and Prevention. Smoking Cessation. Smoking and Tobacco Use. Available at: Accessed August 12, 2012.

The same may be true of marketing efforts behind smoking cessation aids, and there are various possible pathways that could lead to an inadvertent reduction in the rate of quitting or smokers’ persistence in their quit attempts.1 Cummins explains that advertising the importance of the quit aids may carry another message such as “You can only quit if you have a quitting aid.” This is not true for everyone (remember that 63% of smokers succeed on their own), and the message can undermine smokers’ confidence in quitting on their own. Another possibility is that hearing the ads for quitting aids makes smokers assume they will be able to quit whenever they want to, thereby decreasing any sense of urgency for quitting.

“We don’t have an exact understanding of which of these play a role or whether all of them do, what the proportion of their impact is, or even which are the more important factors,” Cummins says, suggesting the area is rich for research. “The main recommendation is that there be more discussion between the research community and public health leaders to ensure that policies do not inadvertently negatively impact the population quit rates,” she says.

Reaching Out

Research has been key to development of the California Smokers’ Helpline, operated by the cancer center and funded by the California Department of Public Health Tobacco Control Program through Proposition 99, the 1988 Tobacco Tax Health Protection Act, and Proposition 10, the California Children and Families Act enacted in 1998 at the local and state levels.

“The California Department of Public Health, which used to be called the California Department of Health Services, saw the potential in quitline intervention for smoking cessation, and Proposition 99 was passed by the state voters. It increased the tobacco tax by 25 cents and dedicated 5 cents to set up a comprehensive tobacco control program,” Cummins says.

Some of the money was used to conduct antitobacco media campaigns to change the smoking norms in the state. Some was allocated through a competitive grant for services to help smokers quit. The California Smokers’ Helpline was one of the programs to receive a grant.

The need and the supporting evidence were strong. In the 1980s, California had offered a toll-free cancer information service. “One of the things [the service] found was that a lot of people called in about smoking. It didn’t have much infrastructure to help with that, but it gave [the service] some idea that smoking was something people were concerned about,” Cummins says.

When John Pierce, PhD, now professor of family and preventive medicine and director of population sciences at the UC San Diego Moores Cancer Center, first joined the team, he expanded upon the work he had done in Australia setting up a quitline. “Although there was limited assistance available, and it was never formally tested, it demonstrated a demand for telephone counseling for smoking cessation,” Cummins says.

The first move in San Diego was to gather research, so the team conducted a large randomized trial with more than 3,000 smokers. “The results showed that telephone counseling doubled the rate of quitting,” Cummins says. The quitline was established a short while later, in 1992.

The California Smokers’ Helpline offers telephone-based services in six languages (English, Spanish, Cantonese, Mandarin, Korean, and Vietnamese). Smokers, or nonsmokers who are interested in helping someone quit, can call one of the language-specific toll-free phone numbers. Materials are then sent in the mail, and they are eligible to receive telephone counseling services. “Counseling prepares them to quit and provides support through the first month of their quit attempt,” Cummins says.

Cessation Support

Over the years, the organization has developed specialized protocols for populations that may require a special approach: teen smokers, pregnant smokers, Asian-language smokers, and smokers with mental illness. Each has a unique barrier to overcome: the pregnant smoker may not really want to quit but is concerned about the health of the baby; Asian-language smokers tend to avoid call lines; and mental health patients smoke in larger proportions than other groups.

“Developing programs for these groups and proving their efficacy have kept us fresh,” Cummins says. “We’ve been trying to move away from the concept that there’s a perfect time or a perfect plan to quit.”

Rather than let smokers aim for a target date in the distant future, leaving more time to veer away from the idea (and continue to smoke), the UC San Diego Moores Cancer Center/California Smokers’ Helpline has moved toward a counseling protocol that helps the smoker jump right into the quitting process. “We try with their first call-in to set up a quit date and go for it. If they’re willing to go straight into counseling, we want to always have a counselor available,” Cummins says.

If the patient insists on waiting, the counselor will try to get them to stop smoking for just 1 day. Every quit attempt teaches smokers something about themselves. “They have to learn about themselves: what works and what doesn’t,” Cummins says.

The protocols are ever-evolving, particularly in response to new research; and the center can produce data to support current initiatives, including the most recent paper. “We believe that the current emphasis on making a quit attempt is consistent with the results of the study. Anything that increases motivation to take action now and that increases smokers’ confidence about their ability to quit will increase the population impact of the program,” Cummins says. And this is a good thing because smoking kills. Everybody knows it—including smokers.

Renee Diiulio is a contributing writer for RT. For further information, contatct [email protected].

  1. Centers for Disease Control and Prevention. Smoking Cessation. Smoking and Tobacco Use. Available at: Accessed August 12, 2012.
  2. Pierce JP, Cummins SE, White MM, Humphrey A, Messer K. Quitlines and nicotine replacement for smoking cessation: do we need to change policy? Annu Rev Public Health. 2012;33:341-56.