This special issue of Tobacco Control contains the presentations and discussions at the conference “ Issues in Smoking Cessation: Who Quits? Who Pays?” held in Washington DC on 13 and 14 April 1993. Although they were focused on the US, the many thoughtful observations and comments that follow provide a broad-based insight into the current state of smoking cessation and much of the research, policy and health service efforts aimed at eliminating smoking from society. One cannot help but be impressed by the growth in the knowledge base about nicotine addiction, and cessation in general, and by the continuing challenge of delivering that knowledge to smokers who want to quit.

The conference also underscored the dynamic environment that influences smoking and quitting. Consider a few of the events that preceded the conference and figured prominently in the discussions. Cigarette companies reported great success selling cheaper cigarettes, possibly slowing the three-decade-long decline in smoking prevalence. Pharmaceutical companies launched the trans- dermal nicotine patch and attracted millions of smokers. The US Agency for Health Care Policy and Research announced its intention to develop guidelines for smoking cessation. And a new administration took office, banned smoking in the White House, promised to emphasise prevention in its health care reform proposal, and threatened to finance reform with a massive increase in the federal cigarette excise tax.

Developments since April 1993 have been no less dynamic. Demand for the transdermal patch has fallen dramatically, perhaps due to unreasonable expectations by smokers and inadequate cessation support from health care providers. The US Food and Drug Administration issued a ban on over-the-counter smoking deterrent products unless and until the manufacturers show safety and efficacy. The administration’s health care reform proposal has been introduced, and while smoking cessation is part of the basic benefit package, it is in an optional category titled “health education classes.” And, the administration is proposing to raise the excise tax by 75 cents, not the increase of $2 per pack advocated by health groups.

This rapidly changing environment, full of opportunity and risks for smoking cessation, suggests that the kind of dialogue about cessation present at this conference and at its predecessor at Harvard in 1989, needs to happen more often. Rather than satisfy ourselves with stimulating discussions, perhaps we need to define a more ambitious agenda for responding to, if not influencing events, and formulating a more coherent national view of cessation. The conference and current events show how much remains to be done if we are to convince more smokers to try, more people to pay for, and more providers to provide smoking cessation.