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The Challenges of Smoking Cessation

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Published Online: Jul 26th 2022 touchREVIEWS in Respiratory. 2022;7(1):4–5
Authors: Richard van Zyl-Smit
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Richard van Zyl-Smit
Prof. van Zyl-Smit is Consultant Pulmonologist at Groote Schuur Hospital in Cape Town, South Africa. He is Professor and Deputy Head of the Division of Pulmonology at the University of Cape Town. His research interests include airway diseases, specifically asthma and chronic obstructive pulmonary disease (COPD) with a focus on tobacco, household air pollution, electronic cigarettes and their impact on pulmonary immune responses, and the development of COPD. He is also currently President of the South African Thoracic Society, the South African representative on the Global Initiative for Chronic Obstructive Lung Disease assembly and a Global Initiative for Asthma global ambassador.


Smoking, smoking cessation, global health, policy, healthcare provider


Smoking is one of the biggest avoidable causes of morbidity and mortality worldwide and is a significant burden to healthcare systems. Without intervention, the annual total of 7.69 million deaths and 200 million disability-adjusted life-years caused by smoking are likely to increase over the coming decades.1 Several smoking cessation interventions have proven to be effective; however, most smokers who try quitting, fail to quit for 6 months or longer.2

In an expert interview, our Editor-in Chief, Professor Richard van Zyl-Smit, discusses the challenges of smoking cessation and how they might be overcome.

Q. Could you give us a brief overview of the global health burden caused by smoking?

The enormous global burden of smoking is surprising given the risks associated. Estimates vary, but around 1 billion people smoke globally and of the top eight causes of death, including hypertension, stroke, heart disease and infection, all have risks that are associated with tobacco smoking.3 It is a risk factor for almost every chronic disease and, particularly, every cancer.4

Q. How have policy makers and healthcare providers acted to combat smoking?

The two groups tend to work on different tracks. The policy makers are the groups that ban smoking in public places and advertising, and increase taxes. This makes smoking less desirable and visible, and more expensive and restricted, thus creating an environment that is supportive of quitting but also restricting. Meanwhile, there is the individual smoker, who is still addicted to nicotine and struggles to break the habit. The healthcare providers need to provide support and care. The two groups are fundamental but rarely talk to each other. We need policy makers and healthcare providers to work together to the benefit of the individual smoker.

Q. What are the challenges to implementing smoking cessation strategies around the world?

There are multiple challenges. From a policy point of view, the income generated by tobacco sales and taxation is substantial, and the influence of the tobacco industry is widespread and universal. It is a countrywide challenge for the governments and institutions to ban smoking, which benefits them in terms of revenue. From an implementation point of view, interventions such as banning sales and advertising are all actively opposed by the tobacco industry. Therefore, implementing any framework convention on tobacco controls and policies to reduce exposure to tobacco can be quite difficult.

Individuals in certain countries are offended by bans on tobacco sales and individual freedom of association, which is a further challenge. In South Africa, the sale of tobacco was banned but the black market flourished, and people spent enormous amounts of money buying cigarettes when it was a clear risk factor for coronavirus disease 2019 (COVID-19). For the individual smoker, there is a significant habit and addiction issue with nicotine usage and tobacco smoking. If the habit and addiction side of smoking is not dealt with, people will spend money buying something that they require chemically. Similar to obesity, alcohol use or any addiction, this habit is extremely difficult to break. Individuals who smoke will potentially require support and encouragement. Pharmacotherapy, which is not easily available, and behavioural therapy are needed to cope with the stresses of life for which smoking is often a relieving factor.

Q. What can public health and other healthcare professionals do to overcome these challenges?

At policy level, healthcare providers could comment on and support local regulations. If local hospitality venues have policies, or are not obeying the regional or local policies, individuals could protest and seek law enforcement for tobacco regulations that are not being upheld. Individuals need to become advocates for the law. If all healthcare practitioners engage with patients and ask the question “do you smoke and have you thought of quitting?”, it could significantly increase the potential for that individual to try and quit. The attitude needs to be ‘pro-smoker’ but not ‘pro-smoking’ to provide the space, motivation and support for smokers to break the habit and the addiction.

Q. What interventions should take priority in the coming years?

The biggest intervention is to provide the support to enable individuals to quit. There has been enormous focus on the policy side, but we have seen that during COVID-19, individuals have struggled to quit even when it became known that smoking was a high-risk factor for COVID-19. Strategies to help individuals, not just pharmacotherapy but community-level strategies to help individuals break the habit, are critically important and should be a greater priority than policies at present. However, we cannot have one without the other. 

Article Information:

Richard van Zyl-Smit has no financial or non-financial relationships or activities to declare in relation to this article.

Compliance With Ethics

This article is an opinion piece and does not report on new clinical data, or any studies with human or animal subjects performed by any of the authors.

Review Process

This is an expert interview and as such has not undergone the journal’s standard peer review process.


The named author meets the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, takes responsibility for the integrity of the work as a whole, and has given final approval for the version to be published.


Richard van Zyl-Smit, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, 7925, South Africa. E:


No funding was received for the publication of this article.


This article is freely accessible at © Touch Medical Media 2022


Medical writing support was provided by Katrina Mountfort of Touch Medical Media and funded by Touch Medical Media.

Data Availability

Data sharing is not applicable to this article as no datasets were generated or analysed during the writing of this article.


  1. GBD Tobacco Collaborators. Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990–2019: A systematic analysis from the Global Burden of Disease Study 2019. Lancet. 2021;397:P2337–60.
  2. US Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon. Available at: 12 July 2022).
  3. World Health Organization. Tobacco. Available at: (Accessed 18 July 2022)
  4. Centers for Disease Control and Prevention. Smoking & Tobacco Use: Health Effects. Available at: (Accessed 18 July 2022)

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