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Editor,—In many former papers,1-4 the smoker's career is described separately for the processes of initiation and cessation. Furthermore, the recently advocated issues of smoking reduction, sometimes followed by a secondary cessation5-7 are not always considered. We have tried to summarise the complete smoker's career in one single schema (fig 1) in a way that could be useful for teaching purposes in the preventive and curative fields.
The non-smoker (A), after a preparatory stage, becomes an occasional smoker (B) (trying and experimentation stages) and afterwards, exceptionally abandons smoking. In most cases, however, experimental smokers progress toward regular, daily use (C). The stage labelled “happy smoker” (D) usually lasts for many years, after which smokers perceive more acutely the “pros” and “cons” of their tobacco use, thus becoming “ambivalent smokers” (E). Later on, some prepare to stop (F), and start to take action (primary cessation) (G), which is sometimes followed by perseverance (H). In most cases, because of withdrawal symptoms, cessation is followed by a relapse (I) and the smoker progresses further, often several times, into the cessation cycle through the stages of “ambivalence” and “readiness to stop” before finally succeeding with cessation and becoming a persistent “happy ex-smoker” (H). Some smokers are unable to quit completely but can space their smoking, again becoming occasional smokers (sometimes by using pipes, cigars or cigarillos instead of cigarettes), while others reduce their daily cigarette consumption, often nowadays with the help of concomitant nicotine substitution, in a process of “harm reduction”. Some of these smokers finally quit (secondary cessation) (J) to also become “happy ex-smokers”. However some remain continuing smokers (K) until their death.
In most cases, the process evolves in the described direction, but, as recently stressed by Butler and colleagues,8 unfortunate interventions, especially at the stage of ambivalence, can induce a regression in the cessation cycle and delay quitting by reinforcing the smoker's resistance to change.
Personal variables largely influence the speed of movement through both the initiation and cessation cycles, while external interventions as well as emerging anti-smoking social norms are conducive to change.
A universally applicable quantitative assessment of the mean durations of the various stages is not feasible, since they differ according to different settings. Similarly, the distribution of the population of smokers in the various stages also differs according to national, ethnic, and socioeconomical parameters.