Tob Control 22:i33-i35 doi:10.1136/tobaccocontrol-2012-050767
  • Commentary

Large-scale unassisted smoking cessation over 50 years: lessons from history for endgame planning in tobacco control

Open Access
  1. Melanie A Wakefield2
  1. 1School of Public Health, University of Sydney, Sydney, New South Wales, Australia
  2. 2Centre for Behavioural Research in Cancer, Cancer Council Victoria, Carlton, Victoria, Australia
  1. Correspondence to Professor Simon Chapman, School of Public Health, University of Sydney, Sydney, NSW 2006, Australia; simon.chapman{at}
  • Received 11 September 2012
  • Revised 10 December 2012
  • Accepted 11 December 2012


In the 50 years since the twentieth century's smoking epidemic began to decline from the beginning of the 1960s, hundreds of millions of smokers around the world have stopped smoking permanently. Overwhelmingly, most stopped without any formal assistance in the form of medication or professional assistance, including many millions of former heavy smokers. Nascent discussion about national and global tobacco endgame scenarios is dominated by an assumption that transitioning from cigarettes to alternative forms of potent, consumer-acceptable forms of nicotine will be essential to the success of endgames. This appears to uncritically assume (1) the hardening hypothesis: that as smoking prevalence moves toward and below 10%, the remaining smokers will be mostly deeply addicted, and will be largely unable to stop smoking unless they are able to move to other forms of ‘clean’ nicotine addiction such as e-cigarettes and more potent forms of nicotine replacement; and (2) an overly medicalised view of smoking cessation that sees unassisted cessation as both inefficient and inhumane. In this paper, we question these assumptions. We also note that some vanguard nations which continue to experience declining smoking prevalence have long banned smokeless tobacco and non-therapeutic forms of nicotine delivery. We argue that there are potentially risky consequences of unravelling such bans when history suggests that large-scale cessation is demonstrably possible.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

Responses to this article