Smoking cessation : alternative strategies is the fourth major conference on cessation and policy issues held in the USA since 1988. And this is the second time that Tobacco Control has given the proceedings of these conferences broad exposure through a supplement. Each of the conferences has aimed to broaden our thinking on cessation, and may have helped balance the perspective of the tobacco control movement between considerations of policy and cessation. For no matter how effective policy interventions may be at motivating smokers to quit, the sad reality is that the success rate for the majority who try to quit on their own is painfully low and much remains to be done to increase both the overall rate of success and the number of smokers who attempt to quit.

At the 1993 conference, considerable interest was generated by new developments that could stimulate support for cessation programmes and products. The US Congress was debating reform of the American health care system. There was great hope that preventive programmes, and especially smoking cessation, would benefit from this high level attention and from an increase in the federal cigarette excise tax. After the conference, health care reform and the excise tax increase failed to pass, and the US smoking prevalence failed to decline appreciably.

The 1995 conference introduced a topic relatively new to smoking cessation - harm reduction - and posed questions with national and international relevance : Have existing smoking cessation strategies and programs failed or reached the limits of their effectiveness? How prevalent and accessible are the cessation aids that have been developed? Will the forthcoming US Agency for Health Care Policy and Research guidelines for smoking cessation and prevention have a major impact on the delivery of cessation by managed care and individual clinicians? Should harm reduction, a controversial but widely accepted concept with other drug addictions, become an integral part of tobacco control efforts? Is harm reduction, or smoking reduction, an acceptable alternative end point to total cessation? Is smoking reduction a meaningful stage in the process of total cessation? These proceedings are rich with discussion of these and other questions relevant to cessation policy, programme design, and service delivery.

The conference also reflected what may be another potential watershed for smoking cessation : the intensification and diversification of commercial interest in cessation products. There were no fewer than 15 commercial firms represented among the sponsors and participants of the conference, with nicotine and non-nicotine products under various stages of development or consideration. As the cover of this supplement shows, commercial interest in smoking cessation dates at least to the late 19th century when the renowned illustrator Maxfield Parrish portrayed “King No-To-Bac” vanquishing nicotine. Perhaps if the product (a gum) and the promotional illustrations had been more effective, the plague of cigarette related death might never have materialised. However, the more powerful tobacco interests clearly overcame the king, and the tobacco “habit”, now more properly recognised as nicotine addiction,¹ leaves us with slowly declining prevalence in the USA and Europe, and a growing international tobacco epidemic.

The potential which these commercial interests represent is substantial: increased diversity in the types of cessation products available, both by prescription and over the counter; increased marketing of cessation products to health care providers ; consumer advertising of an unprecedented scope that may motivate many more smokers to quit; and most important, increased chances for success for those who attempt to stop smoking.

Like all new developments, this carries with it both opportunity and responsibility, particularly for the tobacco control field. Should we simply welcome the increased involvement of major commercial interests in cessation and play no role in shaping the direction of this potentially powerful evolution? Who leads in formulating policy on cessation, or should there be policy at all ? What is the appropriate governmental role, beyond regulating the safety and efficacy of these products, and who sets the standards for efficacy ? What end points are acceptable for new products? How do we ensure that promising new products benefit all smokers, especially hard-to-reach smokers in developed and less developed countries ? What role can public health agencies play?

The presence of so many commercial interests at the conference afforded an opportunity for interaction between the representatives of these pharmaceutical and consumer product companies and researchers, clinicians, providers, payers, public health policy makers, and advocates. Clearly, mechanisms should be found to continue this dialogue in the months and years ahead to ensure that the growing commercial side of smoking cessation benefits from the experience and perspectives of the tobacco control field.