In 1985 I argued for the abandonment of smoking cessation clinics,1 which make an inconsequential contribution to reducing smoking in whole populations2 – the test of their public health significance. Their labour intensity devours resources that could be better used in mass campaigns3 to motivate cessation in far more smokers than the best evidence shows are interested in attending clinics, let alone benefiting from them.

But the most powerful argument against a frontline role for clinics is their reiterating message that “You need help and are unlikely to succeed alone.” Over 25 years, with the advent of nicotine-replacement therapy (NRT), buproprion and varenicline, this arguably misleading message has been turbocharged through heavy pharmaceutical advertising directed at both consumers and physicians. Whilst legions of clinical trials4 and more equivocal real-world evaluations5 show that assistance improves cessation, unassisted cessation remains the preferred and most successful method used by most ex-smokers.

Today’s sustained medicalisation of cessation epitomises Ivan Illich’s concept of a disabling profession.6 It purposefully erodes smokers’ confidence in taking control of a process that hundreds of millions of ex-smokers globally have demonstrated works better for more than any other. Typical of this medicalisation, a recent Lancet seminar on tobacco addiction7 devoted just half a sentence in ten pages to the rhinoceros in the living room: that some 25 years after the advent of NRT, there remains daylight between unassisted cessation and the population cessation-yield obtained by all other methods combined.89

Acknowledging Julian Tudor Hart,10 I propose the inverse impact law of smoking cessation. This law states that the volume of research and effort devoted to professionally and pharmacologically mediated cessation is in inverse proportion to that examining how ex-smokers actually quit. Research on cessation is dominated by ever-more-finely tuned accounts of how smokers can be encouraged to do anything but go it alone when trying to quit – exactly the opposite of how a very large majority of ex-smokers succeeded. The virtual silence about this undeniably positive news reflects the dominance of those whose careers depend on continuing to offer and evaluate labour-intensive regimens and the influence of the drug industry, which has a vested interest in prolonging cessation and in repeat attempts after relapse.

Those impertinent enough to note the continuing dominance of unassisted cessation among ex-smokers and to encourage smokers to go it alone are regarded as heretical, so pervasive is the inverse impact law of smoking cessation I describe and the imperatives for researchers to inhabit its doctrine. Disciples of the law are preoccupied with success rates, when success numbers are what really matter in public health. Extrapolating from Californian data for 1996,11 of 1 million smokers attempting to quit, I calculate that nearly twice as many smokers (60,999) quit unaided than with any form of help (33,014), despite many years of NRT availability.12 I know of no population data from any nation since that shows otherwise.

Cold turkey is routinely framed as the enemy of effective smoking cessation, a kind of amateur half-hearted approach to cessation, when it ought to be embraced as the first-choice method that over decades has consistently assisted far more than any other approach. Failed quit attempts (the average ex-smoker can experience up to 14 of these13) should be redefined as normal rehearsals for success, the unassisted quitting experience demystified as how most people actually quit, and pharmacotherapy restored to the perspective it deserves.

The English approach to cessation epitomises the legacy of the law I propose. There, tobacco-control expenditure has been heavily focussed on dedicated smoking-cessation services, requiring attendance at individual or group counselling sessions with emphasis on NRT. A 2005 report that examined the contribution of this program to reaching a national smoking prevalence target of 21 percent by 2010 stated:

However, in a remarkably understated next paragraph, the report continues:

Australia, by contrast, has negligible cessation services and since 1997 has run large scare-based15 campaigns to motivate quit attempts. Daily smoking prevalence in those aged 14 years and older has fallen by 30.2 percent, from 23.8 percent in 1995 to 16.6 percent in 2007,16 with only 3.6 percent of adult smokers having ever even called the Quitline.17 While pharmaceutical advertisers coattail the governmental campaign, the latter has never given centre stage to messages implying that smokers need help. We need to restore smokers’ confidence in their ability to do what literally millions of smokers have done for many decades without having to rely on help.