I can’t recall smoking my first full cigarette. I was probably around 14 or 15, had long been intrigued about smoking and had taken occasional drags on friends’ furtive offerings away from the sight of parents. I thought a lot about the cachet I would instantly be given once people knew I was a smoker. I knew it would add to the usual gormless adolescent preoccupations of being respected as cool and edgy by friends.

In my teenage years in the 1960s, cigarette advertising wallpapered every media outlet in Australia. My tastes in music and fashion were very different to the sons of central western district farmers at the boys school I attended in country New South Wales. It was a similar story with smoking. Those who smoked mostly bought popular brands like Rothmans, Craven A or Viscount. When it came time for me to buy my first cigarettes, I needed to ask for a brand and I thought carefully about the statement I hoped I might make to others by my choice. My first brand was Country Life, a minor brand that I vaguely recall thinking would somehow stand out more than the brands that others smoked.

I hid them in a cavity in our garage roof and quietly got the pack down when I was going to a party or meeting up with friends at the local swimming pool. The ability to produce a pack of cigarettes in the right circumstances was important; you needed to have cigarettes and other rich clandestine signifiers at hand when an impression needed to be made. I also carried condoms long before I ever had an opportunity to use them, and I had an older friend who was happy to go into pubs to buy me cans of beer when these purchases were also needed to impress others. The first Country Life pack took me months to finish. I found actually smoking them rather than just showing them around pretty unpleasant.

At university I continued to smoke. I remember buying brands I calculated would add some intrigue. There was a specialist tobacconist in Sydney’s Potts Point which stocked evocative brands I’d encountered in novels or seen in ponderous European art-house films: Senior Service, Camel, Gauloises, Gitanes, Sobranie Black Russian and Abdulla. I bought all of these at different times. I smoked every day and more than I did at school, but a pack would still usually last me all week.

My early personal interest in cigarettes as an identity-signalling prop later morphed into an academic interest when I’d finished with smoking. As an undergraduate, I’d read Erving Goffman’s 1956 sociological classic The presentation of self in everyday life and thought about what his ideas meant for the appeal of smoking and cigarette brand choice. My 1984 PhD on the semiotics of tobacco advertising was co-supervised by Henry Mayer, then Professor of Government at the University of Sydney. Mayer is described in the Australian Dictionary of Biography as “the founding father of the study of mass communication in Australia” (Goot 2014). When we first met, he encouraged me to read French essayist Roland Barthes’ Mythologies (London: Paladin, 1973) and to think about the application of anthropologist Claude Lévi-Strauss’ work on totemism to the way that advertising communicated with consumers and provided almost totemic identification and loyalty to different brands. Judith Williamson’s Decoding advertisements (London: Marion Boyars, 1978) and Varda Langholz Leymore’s Hidden myth: structure and symbolism in advertising (London: Heinemann, 1975) were also very influential on my thinking.

My PhD thesis was titled Cigarette advertising as myth: a re-evaluation of the relationship of advertising to smoking. An edited version of it was later published as Great expectorations: advertising and the tobacco industry (London: Co-media, 1986). A central part of it looked at different Australian cigarette-brand advertising, and the ways in which the themes and propositions in branding offered promises that could alleviate a variety of problems (insecurity, isolation, ordinariness, wanting to stand out from or merge with a peer group, concerns about smoking and health, people thinking you were not very smart if you smoked, and so on). Advertising proposed to smokers that they were winners, not losers; leaders not followers; or followers not leaders for those who walked to the beat of that drum.

​Quitting cigarettes

But for all their value in conspicuously badging my evolving identity to others in those early years, right from the beginning I never really enjoyed cigarettes. I knew and accepted what was said about smoking being bad for your health. But I also thought everything except the first puff tasted acrid and unpleasant. So when I started working for the NSW Health Commission when I was 24, I saw this as a great excuse to stop buying them. For a few years I’d still occasionally take a cigarette when one was offered but rarely finished it.

Unlike some ex-smokers, I don’t remember the day when I stopped. I also don’t recall going without smoking as being in any way difficult or unpleasant. There was no sudden stop. I just drifted out of it and didn’t think of myself anymore as someone who smoked. I didn’t miss smoking, and experienced nothing remotely like withdrawal when I tried to stop. In fact, I didn’t have to try to stop, I just decided I would. Despite smoking for about 10 years at least weekly and often daily from the age of 16, it was likely that I was not addicted to nicotine, and like the seldom-mentioned experience of many ex-smokers, I had experienced little if any difficulty or stress in quitting. This book will discuss how widespread my way of stopping has always been in a surprisingly large proportion of former smokers, while the smoking-cessation industry relentlessly frames quitting as being hugely protracted and difficult.

Toward the end of the 1970s, I became immersed in tobacco control through my work and especially through efforts with colleagues to politicise government inaction on tobacco industry advertising and promotion (Chapman 1980). While I was mainly engaged in advocacy to end tobacco advertising, population-wide smoking cessation – how to maximise the number of smokers throughout the population who quit – was also something with which I became very interested.

In those days – as now to a lesser extent – talk in my work environment about quitting smoking was preoccupied with interventions directed at individuals, either alone or in small groups. The Seventh-day Adventist Church had long run its 5-Day Plan (since 1959). Efforts were made to get smokers to go along to meetings across five days with the target of quitting on the fifth day. There were folksy tips about drinking lots of water between meals, distracting yourself by eating carrot sticks and avoiding situations where one usually smoked, as well as opaque references to a higher power. Predictably, the non-smoking, non-drinking, non-gambling and vegetarian church also counselled smokers to not drink alcohol when trying to quit. But nothing in this advice was supported by anything that today would pass as credible, robust evidence about efficacy or effectiveness in smoking cessation.

When we in the Health Commission enquired with the Adventists about how frequently their courses were run and how many people might be able to attend, the information we received was very vague. It seemed that what was on offer was quite a lot less than any vision of a proliferation of courses being run each week across Sydney’s vast suburbs, let alone beyond into country areas. No numbers were forthcoming on whether attendance at the few courses on offer could be counted on two hands or was something far more substantial, with packed halls and long waiting lists. Beyond claims about percentages of smokers who had quit smoking on the last night of their courses, I never saw anything remotely approaching any formal evaluation of what they were doing in Australia, although several papers had been published in the USA showing lasting success in quitting in a small minority of attendees, for example (Thompson and Wilson 1966).

With such reticence about the reach of what they were doing, it seemed obvious that there was likely almost zero match between the vast number of smokers across Sydney who wanted to stop smoking and the ability of the local 5-Day Plan organisers to accommodate even a miniscule fraction of these numbers. This was a fundamental early insight that quickly took root in my instinctive assessment of claims being made and informed the way I came to think of organised efforts and products designed to help smokers quit.

​Early Australian efforts at promoting quitting

From the early years of the 20th century, there has been a long history in Australia, as elsewhere, of urgings and later advice to smokers to quit. In the early decades, this was mostly delivered by Christian temperance movement groups, with core messages that smoking defiled the temple of the body and displeased God. There was early emphasis on preventing youth (especially boys) from smoking, with parliamentary acts preventing sales to youth passed in NSW (1903), South Australia (1904), Queensland (1905), Victoria (1906) and Western Australia (1917). The boy scout movement promoted founder Robert Baden-Powell’s view that smoking stunted the body and befuddled the brain (Walker 1984, Tyrrell 1999). Powell wrote

In the 1950s, considerable news coverage was given to early epidemiology examining the association between smoking and lung cancer, starting with two seminal case-control studies from England (Doll and Hill 1950) and the USA (Wynder and Graham 1950). The US-based Reader’s Digest, which enjoyed wide subscriber-based circulation in Australia, covered these studies (Parssinen 2017). Australia’s peak health advisory group, the National Health and Medical Research Council (NHMRC), first raised smoking with the Minister of Health in 1957, recommending, “States should commence publicity campaigns (i) to warn non-smokers against acquiring the habit of smoking (ii) to induce habitual smokers to cease smoking or to reduce consumption” (NHMRC 1957).

The NHMRC’s recommendation had profoundly little impact on government policy. Sixteen years later in 1973, and seven years after the USA became the first nation to do so, Australia legislated our first timid cigarette-pack warning – “Warning: Smoking is a health hazard” in a tiny font at the base of packs in a colour that was easily lost against the pack colours (Chapman and Carter 2003). Nearly one in three 10–12-year-old Sydney schoolchildren thought “hazard” meant “habit”, a confusion that undoubtedly would have delighted tobacco industry lobbyists at the time in their negotiations with government over the preferred wording (Long 1975).

Governments had published sporadic anti-smoking posters and pamphlets in the 1960s. In the early 1970s, the Anti-Cancer Council of Victoria (now Cancer Council Victoria), led by tobacco control pioneer Nigel Gray (1928–2014), produced and broadcast a number of satirical anti-smoking television advertisements that were run only a few times because of budgetary constraints, but attracted widespread public attention because of efforts by advertising authorities to ban them (Cancer Council Victoria 2020). The consumer magazine Choice, which commenced publication in April 1960, gave early priority to warning about the health effects of smoking. Its May 1961 issue included analysis of the effect of cigarette filters in removing “solids” from smoke that was inhaled through the filter (Choice magazine 1961). The filters performed woefully, as shown in a simple YouTube demonstration (TLB Productions 2007) of the residual black particulate matter (‘tar’) deposited on tissue paper when exhaled after being just held in the mouth and after being drawn deep into the lungs.

There was also considerable news media attention given to the harm caused by smoking, as well as to the dissembling activities of a small number of local (Chapman 2003a) and visiting doctors (Chapman 2003b) who assisted the tobacco industry in its global “smoker reassurance” efforts (Francey and Chapman 2000). Tobacco retail trade magazines from the 1950s described strategies used by tobacconists to assuage nervous smokers’ concerns about health problems (Tofler and Chapman 2003). They frequently proposed that diseases such as lung cancer were caused by industrial and motor vehicle pollution, not smoking.

I have large folders of photocopied Australian newspaper clippings dating from the 1950s about smoking and health. As an expert witness in litigation, I was provided these by law firms acting for plaintiffs dying from mesothelioma, a cancer of mesothelial tissue, associated especially with exposure to asbestos, who were suing asbestos companies for negligence (Heenan 2006). Many of these plaintiffs were also smokers and the asbestos companies were seeking to argue a defence of contributory negligence in asbestos-exposed plaintiffs who “chose” to smoke, despite the widespread negative publicity. With smoking in men being very widespread in the 1950s and ’60s, this was the situation of many of the mesothelioma victims. While this news coverage was dominated by items covering health risks of smoking, there were also many which focused on the “controversy” about whether smoking was in fact risky. There has been a good deal of publicity seen by millions of Australians about the risks of smoking in the 70 years since 1950. Much of this influenced a lot of people to quit smoking. In those early days there was no regular surveying of how many smokers quit which commenced in Australia in the 1970s, so there is no fine-grained data to assist in analyses of how effective news publicity alone was in driving down smoking.

Australia’s first mass-reach quit-smoking campaign

From 1981 to February 1983, I was head of the New South Wales Health Commission’s Anti-Smoking Project Group, with a roving brief to find innovative ways of promoting quitting. The portentous-sounding “group” I headed never consisted of anyone but me and a part-time librarian Edith Falk, whose job it was to build up and disseminate a collection of reports and scientific papers about smoking and how to quit. During this time, the NSW Labor health minister Laurie Brereton, had been persuaded about the importance of running large scale, mass-reach anti-smoking campaigns by an early pioneer, health administrator Bernie McKay, who led Australia’s first significantly budgeted quit-smoking campaign on the North Coast of NSW (Egger, Fitzgerald et al. 1983). The success of this campaign saw it rolled out statewide after McKay was promoted to secretary of the NSW Department of Health in 1982 and lost no time in elevating the North Coast approach to statewide reach.

In 1982, a set of TV, radio and print advertisements were produced by Sydney advertising creative director John Bevins, who had worked on the North Coast campaign and earlier on the pioneering advertisements commissioned by the Anti-Cancer Council of Victoria. An evaluation team was also assembled, led by John Pierce at the University of Sydney. For the first time, Sydney residents regularly saw prime-time, highly professional quit-smoking advertising (Pierce, Dwyer et al. 1986) in what was called the Quit. For Life campaign. A collection of most of these advertisements can be seen on YouTube (Chapman 2020b).

We must provide help!

I was part of the team that implemented the campaign in 1983–84. While it was being planned, voices up and down the bureaucratic tree began insisting that it would be simply unacceptable to raise concerns about smoking in TV advertising and encouraging quitting across the community, without providing “help” to these smokers to do so. This was the first time I’d encountered the idea that if you were wanting to quit, you would benefit from being professionally assisted while you attempted to stop. There was furious agreement with this idea from many of those who had been brought in to advise and work on the campaign.

In fact, it went further than this. Never far from the surface of conversations about quitting was the idea that the best way to quit was to immerse yourself in some new form of innovative talk therapy or procedure – often to have something done to you – that would supposedly greatly increase your chances of quitting for good. We were seeing an early manifestation of clinical psychologists broadening their canvas from the individual in front of them to problems that affected vast numbers of the population.

Plans got underway to open a dedicated quit-smoking centre during the Quit. For Life media campaign, providing various forms of assistance to those wanting help. The idea was that the centre’s staff would offer a smorgasbord of quit assistance from which smokers could choose. Renee Bittoun, who ran a quit-smoking service at Sydney’s St Vincent’s Hospital and had tried to help media mogul Kerry Packer quit smoking after he’d been admitted to hospital in October 1990 after a heart attack, headed the centre. A psychologist from the University of New South Wales, Chris Clarke, who was interested in a new aversive experimental strategy called “rapid smoking” (Danaher 1977) was also in attendance. With the rapid smoking approach, participants smoked several cigarettes in quick succession to try to maximise unpleasant reactions and taste. This procedure was designed to condition smokers to experience unpleasant, aversive associations with smoking when they lit up. Pioneering Russian physiologist Ivan Pavlov’s work on classical conditioning had paved the way for this type of “great idea”.

A publication from the time describing the centre lists six treatment options: hypnosis-assisted therapy; “non-cult” meditation; relaxation; rapid smoking; 14-day withdrawal; and self-control (“this consisted of attention centring on non-cult meditation combined with an abbreviated deep muscle relaxation procedure. It was explained that learning how to combat smoking-related thoughts and images, and physical tensions would provide the self-control necessary to not smoke”) (Bittoun and Clarke 1985).

This was at a time well before any considerations of robust evidence were in the forefront of government and professional recommendations about how to quit. I recall being in a meeting called to discuss who might be suitable to provide “non-cult” hypnotherapy to those who chose it from the clinic’s menu. The yellow pages business phone directory located several of these and some were contacted. Some turned out to be little more than theatrical stage hypnotherapists. There were no clinical accreditation procedures for hypnotherapy in those days, let alone for “non-cult meditation” or “relaxation”.

“Relaxation” sessions had enjoyed a period of being fashionable in health promotion professional circles in the 1970s in Australia. I can recall attending staff development courses on a miscellany of issues which often featured periods where softly spoken psychologists would ask everyone to lie on the floor with their shoes off, in the loose clothing we had been requested to wear for the day. Over about 20 minutes, the supine participants would be invited to concentrate on thoughts about progressively relaxing different parts of our bodies, often to the gentle sounds of a tape playing whisper-soft bird, water or rustling tree sounds. I don’t remember dangling crystals or mists of heated essential oils, but you get the picture.

At the end of each session, which sometimes saw participants fall asleep and start to snore, people would sit up and beatifically assure the relaxation session leader that they had been transformed from being stressed and tight to being blissfully relaxed and centred and ready for the stressful challenges of the day.

Somewhere among all this, someone must have thought they had a ripe audience in naïve health promotion leaders from the period for the idea that these rituals could somehow help many thousands of people stop smoking. Yes, it was that amateur – all in the self-evident, unquestioning line of duty to the rapidly emerging dogma that smokers serious about quitting should always be helped. Almost anything was worth trying, it seemed.

The quit-smoking centre was at Sydney Hospital, on the edge of the central business district. It operated for three months, during which time “over 3,500” smokers attended at least one session of the various interventions being offered. Two months after attendance, they were mailed a questionnaire and 2,491 (said to represent 69% of those who attended) were returned. Of these, 738 claimed to have stopped smoking (30% of those returning questionnaires, and 21% of those who ever attended) (Bittoun and Clarke 1985).

In 1983, around 67% of Sydney’s then 3.355 million population was aged 20 years and over and smoking prevalence was 35%. This meant there were some 786,000 over-20-year-old smokers in Sydney. The 738 smokers who said they had quit after attending the centre thus represented one in 1,065 or 0.09% of Sydney’s smokers. And that’s before we consider questions of the reliability of self-reported quit data provided to those conducting the interventions, the absence of any biochemical validation of whether they had truly stopped smoking, and of considerable relapse rates that would have still occurred after two months (JR Hughes, Keely et al. 2004) – see Chapter 2. And it was also before anyone asked the obvious question: how many of the people who attended the clinics would have quit anyway, sooner or later, had they never attended the clinic.

Nascent scepticism starts to foment

Because I had begun working in tobacco control, had quit myself and knew plenty of others who also had stopped smoking, I sometimes asked people how they had gone about stopping. My daily, increasing gut instinct in those very early years of my career in tobacco control was that the growing number of people I knew who used to smoke but no longer did had nearly all stopped smoking without any formal or professional help. This was borne out in a 1975 paper by Nigel Gray and David Hill who reported that by the age of 45, half of those who had ever smoked in Australia had quit (Gray and Hill 1975). The corollary of that instinct was that the galloping momentum among many of my work colleagues to steer people into “professionally” mediated cessation was a castle being enthusiastically built on very wet and avoidable sand.

In the late 1970s, I was very influenced by the writings of Ivan Illich. His Medical nemesis: the expropriation of health (London: Marion Boyars, 1976) explored the issue of iatrogenic medicine – the ways in which the practice of medicine can harm health. He identified three forms of iatrogenesis: (1) clinical, or the direct harm done by various medical treatments; (2) social, or the medicalisation of ordinary life; and (3) cultural, or the loss of traditional ways of preventing and dealing with health problems. I began to wonder if the professionalisation of smoking cessation was an example of this medicalisation, and whether it was undermining “agency” in many smokers to feel confident that they could quit on their own. US critic Stanton Peele’s 1989 book Diseasing of America: how we allowed recovery zealots and the treatment industry to convince us we are out of control (Peele 1989) further consolidated my thinking in the 1990s. I discuss this in Chapter 5.

A 1977 collection of essays by Illich and others called Disabling professions (London: Marion Boyars, 1977) included a piece by American medical sociologist Irving Zola, who wrote about the growing medicalisation of society and the ways in which this often disempowered people to do things they had long done without help. These works were early articulations of a theme that today attracts enormous attention in public health, clinical and health services scholarship: the idea that far less medical and professional intervention can often result in better outcomes for a wide range of health problems.

I began thinking a lot about the application of these perspectives to tobacco control. At the core of what both interested and disturbed me was those back-of-an-envelope calculations I’d done for the Sydney quit-smoking centre which showed the utterly hopeless mismatch between one-on-one or small group approaches to quitting and the vast numbers of smokers who had an interest in quitting. If we were going to make serious inroads into reducing smoking, the approaches to doing this would need to be able to reach correspondingly huge numbers of people, before questions of the effectiveness of those policies and programs were even considered.

Individuals or populations?

When I began running this perspective past colleagues, I found a polarised reaction. There were many who immediately got it. These were people who instinctively understood that with a problem as widespread as smoking, the very first criterion in evaluating the sense in running potential strategies was whether a policy or program could even reach millions of smokers, before questions of how effective these might be were evaluated. If it was obvious that a particular program could never attract the attention of – let alone involve – even tiny fractions of smokers, such programs could never hope to make a small impression in reducing smoking across a population.

Those who thought quit clinics were serious ways of helping lots of people quit smoking were almost invariably clinicians or those employed in the helping professions. Their training and experience involved trying to assist individuals or sometimes small groups of individuals to change. An eye-moistening parable I often used in teaching public health is useful here in distinguishing individual from population-wide perspectives.

A parent and child are walking on a beach and see thousands of fish being washed up on the shoreline by a strong tide. Many of the fish are dead and the rest flap helplessly on the sand. The parent begins to throw surviving fish back into the water, liberating them from their fate one at a time. The child questions the parent, asking what the point is of saving a few fish when inevitably, for each one saved, hundreds or thousands more will immediately take their place, being washed ashore with each wave. The parent replies that while the child’s observation is true, each fish that is saved by their actions will be in no doubt that being helped to live was a good thing.

I told this parable to emphasise that personal acts of generosity, helpfulness, care and attention can make important differences to others. Very relevant here is the concept of the “rule of rescue” (McKie and Richardson 2003), which sees political and resource allocation priority always given to efforts to save identifiable, named individuals, rather than unnamed “statistical” individuals whose lives might be saved or their quality of life enhanced in years to come by policy decisions taken today. Civilised societies always value individuals and so dropping everything and sparing no expense to cure or save them is always valued.

Rescuing individuals – or for our purposes here, assisting people to stop smoking – is nearly always virtuous. People running small interventions in the community such as quit clinics undeniably help some of those who attend their clinics to stop. But a population perspective focuses on the comparative utility of individuals saving fish one at a time, versus efforts to mitigate the factors that are causing so many fish to be washed ashore in the first place, and adopting policies that might trigger large numbers of smokers to quit without enormous investments in labour or drugs.

Many tobacco control policies reach every smoker (for example, widespread smoking restrictions in indoor settings, advertising bans, graphic pack health warnings, taxation increases, plain packaging). Mass-reach interventions like major, well-funded public awareness campaigns are likewise seen by most smokers and might collectively inspire large numbers to try to quit. In Chapter 8, I’ll look at what areas of tobacco control are worth serious government investment and action if a population focus is the canvas.

Over the 47 years of my career, I often saw well-meaning but hopelessly inconsequential small-scale quit-assistance efforts bobbing up in many nations. Between 1982 and 2014, I worked as a consultant or advisor on tobacco control to the World Health Organization, the Union for International Cancer Control (formerly International Union Against Cancer), and Consumers International on 25 occasions in 17 nations. On every one of these occasions, the numbers of those attending the meetings or training workshops I was organising or helping with were dominated by people with clinical orientations.

When we did our introductions on the first mornings and people were asked to say what they did in tobacco control, by far the most common response was that those attending ran smoking cessation clinics in hospitals or community settings, often only occasionally as an add-on to their primary clinical roles. Many kept no records of smoker throughput (how many attended their clinics) or even short-term quit outcomes, let alone well-down-the-track impacts. Yet in many of these nations, there was only the most rudimentary level of tobacco control law, regulation or policy in place. Tobacco control in these nations was often the sum total of the effort of these few individuals trying to coax small numbers of smokers into quitting.

Frankly, the aggregated contributions of these few individually focused people in reducing smoking across whole populations was nothing but spitting into the wind of huge forces which were recruiting people into smoking, keeping them there with industry chemists optimising nicotine addiction (Henningfield, Pankow et al. 2004) and wrecking policies that might seriously slow all this down. Every day, untold thousands of people took their first puff of a cigarette, driven by the marketing efforts of the tobacco industry and by governments which failed to control these promotions.

Early provocations

I began writing about this total futility in 1985, when I was awarded an Australian NHMRC travelling fellowship to London to study the natural history of smoking cessation. Seeing burgeoning examples of quit-smoking clinics in England, I published a deliberately provocative paper in The Lancet called “Stop-smoking clinics: a case for their abandonment” (Chapman 1985). I walked readers through the arithmetical mismatch between the reach and impact of these clinics and any population-wide ambition to reduce smoking throughout England. The paper upset several early leaders in English tobacco control and while I was not run out of the country, I experienced my first taste of the renowned English cold shoulder.

In later years, seeing a major consolidation of resources devoted to assisted smoking cessation (particularly in England – see Chapter 4), I returned several times to this issue, publishing next a short piece in The Lancet titled, “The inverse impact law of smoking cessation in 2009” (Chapman 2009). In this I wrote:

I followed this in 2010 with a longer piece with Ross MacKenzie in PLOS Medicine, looking at the huge research neglect of unassisted cessation, and summarising the factors that together seemed responsible for this neglect (Chapman and MacKenzie 2010). By March 2022, the paper had been accessed over 58,000 times and cited 300 times. I summarise that paper in Chapter 3.

These papers saw me get a lot of invitations to speak at meetings about my argument. As had occurred 25 years earlier when I published my original Lancet piece, key figures in British tobacco control seemed intensely irritated by what I was arguing. I give some examples of this in Chapter 5 where I examine the almost cult-like dogma that so many in tobacco control, particularly in Britain, embrace and defend.

​Outline of this book

For as long as people have smoked tobacco, there have also been many who decided to stop doing it. No one has ever attempted to estimate the total, aggregated number of people across the centuries who once smoked and then no longer did. For almost all of that time, quitting was something that was never studied or counted. I’ve never seen an estimate of total quitting numbers for even the 60-year post-1960 period when quitting accelerated. But as I will consider in Chapter 3, such a figure in global aggregate would number in the hundreds of millions.

Considered against this historical backdrop, “modern” professionalised, pharmaceutical and, most recently, vaping approaches to quitting are all very recent phenomena that have occurred within the five minutes before midnight on a 24-hour clock of the full history of smoking cessation. If we were able to estimate the total number of people who have ever smoked and the total number who later stopped smoking completely, the proportion who were assisted in quitting by the actions of any kind of therapist or interventionist, or by consuming a potion, a pill or nicotine replacement (pharmaceutical, or most recently, from e-cigarettes) would be a small minority.

I have often asked my public health classes, groups of friends around a dinner table and many individuals if they ever smoked but have now quit. I then ask them how they quit. Overwhelmingly, most ex-smokers say they quit without taking any drug, wearing a nicotine patch, seeing a therapist or attending a special clinic. Try that exercise yourself a few times and you will almost certainly have the same experience.

Unassisted quitting is not a phenomenon that is unique to smoking. It is also very common among other dependencies, and this is important to understand. So in Chapter 1, we’ll step away from smoking and briefly consider how people with other addictions and compulsive behaviours end their dependencies. I’ll summarise the evidence about unassisted cessation of problematic alcohol, opiate and cannabis use and problem gambling.

Before turning the focus onto how most people stop smoking, in Chapter 2 I’ll next review the strengths and weaknesses of different types of evidence that are often used to make claims about success rates in quitting smoking. We’ll also look carefully at the great variability in what is meant by smoking cessation – stopping, quitting or remission from smoking, and the core issue of relapse in that understanding. This chapter will lay the bedrock for the subsequent chapters where we will look at the track record of various assisted routes to quitting, and especially the contribution of these to population-wide quitting. I will move from considering the weakest form of evidence – testimonials and anecdotes from those who swear by a particular way of quitting – to looking at stronger forms: randomised controlled trials, cross-sectional “snapshot” and time-series surveys, and cohort studies of large groups of randomly selected smokers who are followed across time to see how many keep smoking, quit and relapse back to smoking.

There are several important biases in studies of smoking cessation: self-selection bias, competing-interest bias, recall bias, positive outcome bias and indication bias. I’ll summarise what we need to know about each of these in interpreting claims for smoking cessation.

I’ll also look at the problem of determining both the whys and hows of successful quitting, including complex questions of attribution: of how clear we can be about what motivated people to quit and what should be best considered the “how” of ex-smokers’ success in completely stopping smoking.

Chapter 3 will examine what we know about how many millions of smokers quit in the eras both before and after the availability of nicotine replacement therapy (NRT), prescribed drugs like bupropion (Zyban™) and varenicline (Champix™), and most recently e-cigarettes. The introduction of these drugs in the modern era of smoking cessation dates from the 1980s when public discussions of quitting began becoming increasingly “medicalised” as a problem best needing treatment. I’ll summarise some of the most important studies looking at the questions of whether the availability of these aids changed both quit attempts and quit successes in real-world settings.

Chapter 4 will look at the track record of various approaches to promoting smoking cessation that have been promoted as having potentially mass-reach impact. These include establishing and promoting networks of specialised quit clinics (particularly in England), efforts to increase doctors’ rates of actively assisting their smoking patients to quit, telephone quitlines, apps and online quit programs, “contingency payments” (paying smokers to quit), and quit and win lotteries.

This chapter will conclude with a look at the evidence about the extent to which interventions that are frequently described and evaluated in research journals and presented at research conferences are ever “upscaled” to become serious ways capable of assisting significant numbers of smokers to quit. When we read a report that shows a particular intervention has been a success, it is perhaps natural to assume that it will soon happen that governments, non-government public health organisations or the private sector will pounce on this good news and start offering the intervention to large numbers of smokers who are clamouring to participate.

As we will see, this is far from the case. In brief, very few behavioural interventions of the type we trip over daily in the pages of research journals ever go on to become routinely adopted into policies and practices which actually reach and affect mass numbers of people who might benefit from that exposure. Most intervention research papers delivered at health conferences and published in journals describe interventions that only those who were exposed in the research project ever experience. They rarely become a routine part of day-to-day communicative, workplace, educational or clinical environments, which was the whole idea in trialling these interventions in the first place. For this reason, much published intervention research is very inconsequential and a distraction from the year-on, year-out ways that see most smokers actually go about and succeed in quitting.

Chapter 5 will look at the way those promoting assisted quitting have attempted to sell and defend their message to smokers and the news media. Here, we’ll take a critical look at the core subtexts of the ways in which advocates for assisted smoking cessation, the pharmaceutical industry and vaping advocates have sought to frame the benefits of assisted cessation. First, I’ll forensically examine the arguments on which the entire pitch for smokers needing assistance rests. The first of these is the “hardening hypothesis”, which posits that today’s smokers are dominated by hardcore, intractable smokers who are deeply addicted to nicotine, have repeatedly failed to quit and are highly unlikely to do so without a leg-up from pharmacological assistance and/or professional support.

Another aspect of often unchallenged folk and professional wisdom is the widely held belief that quitting is often extremely difficult, as attested by the many failed attempts or relapses back to smoking that often characterise smokers’ efforts to quit. As we’ll see, one of the best kept secrets about quitting is that a very sizable proportion of those who quit find it unexpectedly easy to stop. I’ll look at why this is such a closely held secret for many working in tobacco control.

Another dominant narrative is that to quit, a smoker needs to transit through several “stages of change” before they have any real chance of quitting successfully. A first stage has been called the “precontemplation” stage. This is where smokers aren’t considering quitting at all. Many smokers progress to a next stage where they “contemplate” quitting, but don’t take any serious steps to do so. Next comes the preparation, action to quit and maintenance of quitting stages. And then, for many, the relapse stage followed by recycling at a later time through it all again.

The trouble with all this is there is widespread evidence that many people leapfrog several of these stages and suddenly quit, often permanently, without following the neat model pathway laid out in what has been called the transtheoretical theory of behaviour change (Prochaska and Velicer 1997).

Those promoting assisted quitting have frequently denigrated cold turkey as the very worst way of trying to quit by using a number of interrelated strategies. These include the bizarre exclusion and cursory dismissal of unassisted quitting from reviews of “evidence-based cessation”, implying that there is no “evidence” to support unaided quitting as the method that yields (by far) the most long-term successful quitting numbers in whole populations. Clinical guidelines on how clinicians can best promote quitting among their patients routinely give no mention of unassisted quitting.

This chapter will also discuss factors and actors that have and continue to drive the commodified “specialisation” of smoking cessation. It will explore how the medicalisation of quitting over the past 40 years has been an entirely predictable development against the background of the burgeoning commodified medicalisation of common, ordinary human problems which have previously not been medically labelled as pathologies and supervised by clinicians. The dominance of the interventionist paradigm in mainstream tobacco-control thinking dovetails strongly with this medicalisation. The chapter will look at the promotion of, not just cessation medication, but maintenance (long-term or lifetime) medication, multiple medication and even pre-quit medication.

The two principal actors driving the narrative of “don’t try to quit unaided” are first corporations benefitting from as many quit attempts as possible, ringing their cash registers every time a medication is used or an e-cigarette powered on; and second, professional and commercial interventionists wedded to the “take something or do something” school of behaviour change who often find natural alliance with the industries which make such products.

In Chapter 6, I’ll look critically at the latest kids on the block in commodified smoking cessation: electronic cigarettes and other novel nicotine products. The hype about these products is that they are massively disrupting the entire approach to tobacco control because of the twin claims that they are all but completely benign and unparalleled in being useful for quitting smoking. The use of these products has grown rapidly in many nations since around 2010. I’ll look closely at the claims that are made for them about smoking cessation by their advocates and the rather different reality of what we know about how successful they have been. The evidence to date on claims that they are spectacularly effective in helping people quit is sadly the latest outing of an old quit proselytising emperor, this time in new, still threadbare but very flavoursome clothes. My view is that the rise of vaping is just the latest chapter in the history of smoking cessation’s mass distractions. As the saying goes, “Same, same but different.”

Chapter 7 reproduces two edited open-access papers from a wider body of work arising from a three-year Australian NHMRC grant I led and worked on with five others, titled The natural history of unassisted smoking cessation in Australia. This grant produced seven research papers which formed the basis of the PhD thesis I co-supervised of Andrea Smith, awarded in 2018. The first paper is a systematic review of what the qualitative research literature available on unassisted quitting prior to September 2013 reported about the main themes elicited from successful quitters on why they “went it alone” when quitting. The second paper reports original work we conducted with successful ex-smokers in Sydney, and in particular about why these people had chosen not to quit using medications or professional help. This qualitative analysis of the accounts of unassisted quitting remains one of the most detailed examinations of how and why those who take this route out of smoking decide to do it.

Chapter 8 urges that we look at the big picture instead of being preoccupied with the impact of single interventions and policies. We should instead reflect on the huge rhino in the room of smoking cessation: that there have long been more ex-smokers than smokers, that most of them have quit unassisted and that they all were motivated to stop smoking by a complex synergy of factors that played out over years, not just in the final days or weeks before they ended their smoking.

This chapter will briefly summarise the available evidence on policies and mass-reach interventions that have driven smoking prevalence down in many nations which have taken tobacco control seriously. Often these policies have been implemented at glacial pace and interventions given only token funding, greatly reducing their reach. Part of the reason for this is that policies, interventions and assumptions of mass distraction have diverted funding attention and workforce focus away from research, policies and interventions that together promote the idea that smokers have agency or self-efficacy to try to succeed in quitting. We know that these policies collectively can drive smoking down across whole populations but are being sidelined by those in tobacco control who still can’t or won’t see the wood for the trees.

The final chapter in the book looks at policies to control and regulate the supply of tobacco. I compare how tobacco products are sold from literally any retail outlet that chooses to do so, while other products and services have long been subject to strictly enforced regulations around selling and access. The access to scheduled pharmaceutical products is the obvious comparison.

I end the book by looking at so-called endgame arguments for phasing out the sale of combustible tobacco and regulating nicotine vaping products in the ways that other addictive drugs have been regulated for decades.