touchRESPIRATORY coverage of CHEST 2025:

Smoking cessation remains central to managing chronic respiratory disease, yet clinicians face evolving evidence, varied patient needs, and persistent access barriers. Understanding the risks and benefits of emerging tools alongside strategies tailored to diverse populations helps support more effective, equitable quit outcomes.

In this interview, Dr Humayun Anjum (Baylor Scott & White Health, Dallas, USA) explores the current landscape for smoking cessation in patients with respiratory conditions, highlighting approaches to integrating health equity into clinical practice and providing key resources for underserved populations. Dr Anjum also discusses the current evidence surrounding e-cigarettes and practical approaches to individualising smoking cessation.

The talk “E-Cigarettes and Alternative Tools, Health Equity and Access to Resources” was presented at CHEST 2025, 18–22 October 2025, Chicago, IL, USA.

Q. What is the current evidence on e-cigarettes as a tool for smoking cessation in patients with respiratory conditions?

Over the past decade, several randomized controlled trials and systematic reviews have evaluated e-cigarettes (ECs) for smoking cessation. The Cochrane Review (2024 update) found that nicotine-containing ECs increase quit rates compared with traditional nicotine replacement therapy (NRT) or behavioural support alone, with moderate-to-high certainty evidence.¹ However, most studies enrolled generally healthy smokers, and data specific to patients with chronic respiratory diseases, such as COPD or asthma, remain limited.

Among respiratory patients, small observational studies have suggested potential improvements in symptoms, lung function, and exacerbation rates in patients with COPD who switched from cigarettes to ECs. Yet, these studies are limited by small sample sizes, lack of randomization, and potential bias. Conversely, population-based studies have shown increased odds of COPD and respiratory symptoms among EC users, even after adjusting for smoking status. The conflicting data highlight challenges including dual use, variability in product composition, and difficulty in long-term follow-up.

Major respiratory guidelines remain cautious. GOLD 2025 and GINA 2024 both state that there is currently insufficient evidence to recommend e-cigarettes as a cessation aid and continue to endorse approved pharmacotherapies, such as varenicline or combination NRT.^2,3 Although the FDA has authorized certain e-cigarette products for sale, none are approved for smoking cessation.

Overall, while e-cigarettes may represent a harm-reduction alternative for smokers unable or unwilling to quit using approved therapies, their effectiveness and safety in patients with respiratory disease remain uncertain. This uncertainty arises from limited disease-specific data, evolving device technology, and confounding from dual use. Clinicians should therefore view ECs as a potential transitional tool—not a proven cessation therapy.

Q. How should smoking cessation approaches be adapted for patients with chronic respiratory conditions?

Smoking cessation is the most effective intervention to improve outcomes and slow disease progression in chronic respiratory diseases, such as COPD, asthma, and bronchiectasis. These patients often exhibit greater nicotine dependence, reduced self-efficacy, and higher relapse rates, warranting tailored, disease-integrated approaches.

In COPD, cessation should be considered a core component of disease management. The GOLD 2025 report recommends that every encounter should include smoking assessment, counselling, and pharmacotherapy. Evidence supports varenicline and combination NRT as first-line treatments, often requiring prolonged or repeated use. Integration into pulmonary rehabilitation and reinforcement during hospitalization—especially after exacerbations—can leverage key “teachable moments.”

In asthma, cessation leads to better symptom control, improved lung function, and enhanced responsiveness to inhaled corticosteroids. The GINA 2024 guidelines emphasize addressing both active smoking and second-hand exposure. Behavioural support should link quitting directly to improved asthma control, using frequent follow-ups and asthma action-plan reinforcement.

For bronchiectasis, direct evidence is sparse, but cessation remains essential to reduce mucus production, infection risk, and lung function decline. Counselling should be paired with education about airway clearance and exacerbation prevention.

Psychological comorbidities, such as anxiety or depression, prevalent in chronic respiratory disease, should be screened and treated in parallel. Overall, cessation support must be multimodal, persistent, and embedded within chronic respiratory care—transforming every clinical contact into an opportunity for tobacco treatment.

Q. What strategies can help improve access to smoking cessation resources for underserved or high-risk populations?

Disparities in smoking prevalence and cessation outcomes persist among low-income groups, racial and ethnic minorities, rural residents, and individuals with behavioural health conditions. Barriers, such as cost, limited access to care, and low awareness of services contribute to these inequities.

At the policy level, comprehensive insurance coverage for cessation treatments—without co-pays or prior authorization—has been shown to increase quit attempts and success. Yet, many Medicaid programs still impose restrictions, limiting equitable access. Policymakers and clinicians should advocate for barrier-free coverage and integration of tobacco treatment into all healthcare settings, including behavioural health and primary care.

Within clinical systems, opt-out models—in which all smokers are automatically offered counselling, medications, and Quitline referrals—outperform traditional opt-in approaches. Embedding cessation prompts into electronic health record (EHR) workflows and linking patients to services, such as 1-800-QUIT-NOW, improves reach across demographic groups.

Community-based interventions are vital for hard-to-reach populations. Culturally tailored programs, community health workers, and partnerships with local organizations enhance engagement. National campaigns like the CDC’s “Tips from Former Smokers” effectively increase Quitline use among lower-income individuals. Digital resources and mobile health interventions further expand access in rural and resource-limited areas.

In essence, improving access requires a multi-level approach that combines policy reform, healthcare integration, and community engagement. By reducing structural barriers and investing in culturally relevant outreach, cessation services can reach those most affected by tobacco-related disease.

Q. How can health equity be integrated into smoking cessation programs in clinical practice?

Health equity in smoking cessation involves ensuring that all individuals—regardless of socioeconomic status, race, or health condition—have equal opportunity and support to quit successfully. Because tobacco use is both a cause and consequence of inequity, cessation programs must actively counteract systemic barriers rather than apply uniform interventions.

Clinically, adopting opt-out treatment models, embedded in EHR systems, ensures that every patient identified as a smoker is automatically offered counselling and pharmacotherapy. Collecting and analysing cessation data by demographic subgroups enables health systems to identify disparities and evaluate program effectiveness.

Cultural and linguistic tailoring enhances patient engagement. Using bilingual materials, culturally relevant counselling, and community partnerships—such as faith-based groups or federally qualified health centers—improves quit rates in minority populations. The use of community health workers bridges gaps in trust and continuity, especially in rural and underserved areas.

From a policy standpoint, the HHS 2024 National Framework for Tobacco Cessation advocates eliminating cost-sharing and administrative barriers to approved medications, while promoting integration of tobacco treatment into mental health and substance-use programs.⁴ Expanding telehealth, mobile, and pharmacy-based cessation programs reduces geographic inequities.

Equity-focused programs should also screen for and address social determinants of health, such as unstable housing or food insecurity, that undermine adherence. By embedding social support into cessation care and maintaining a non-judgmental, empowering approach, clinicians can reduce stigma and improve sustained abstinence.

In summary, embedding health equity into cessation practice requires systematic screening, culturally competent care delivery, structural reform, and ongoing data-driven evaluation. Doing so transforms tobacco treatment from a standardized intervention into an instrument for health justice.

Q. What practical tips can clinicians use to tailor cessation interventions to individual patient needs and social contexts?

Individualizing smoking cessation interventions enhances their effectiveness, especially in patients with chronic respiratory disease and diverse social backgrounds. The process begins with a comprehensive assessment of nicotine dependence, prior quit attempts, psychiatric comorbidities, and social environment. Using motivational interviewing helps align quitting goals with patient priorities and identifies barriers, such as stress, fear of failure, or limited support.

Pharmacotherapy should be personalized. Varenicline is typically most effective, while combination NRT benefits those requiring flexible dosing or with contraindications. Patients should be counselled that multiple attempts are normal, and failure does not imply futility. For individuals with depression or anxiety, bupropion may offer additional benefit. Ensuring affordability, simplifying regimens, and aligning refills with follow-ups improve adherence.

Social and environmental tailoring are equally important. Clinicians should inquire about home smoking policies, partner smoking, and workplace triggers. Encouraging smoke-free environments and involving family in quit planning increases success. For those facing logistical challenges, telehealth, Quitline counselling, and text-based programs can sustain engagement outside traditional clinics.

Cultural sensitivity further enhances effectiveness. Programs that use community-specific messaging, bilingual education, and trusted local partners outperform generic counselling. Incorporating community health workers or pharmacists extends support, particularly in low-resource settings. Addressing social determinants of health—through referrals for housing, food, or mental health support—removes external obstacles to quitting.

Ultimately, smoking cessation should be managed as a chronic, relapsing condition, requiring empathy, persistence, and reinforcement. Regular follow-up, positive framing of relapses as learning opportunities, and consistent encouragement transform cessation into a patient-centred, sustainable behavioural change that complements medical care for chronic respiratory illness.

References

1. Lindson N, Butler AR, McRobbie H, et al. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews. 2024;1:CD010216.
2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). GLOBAL STRATEGY FOR PREVENTION, DIAGNOSIS AND MANAGEMENT OF COPD: 2025 Report. Available at: https://goldcopd.org/2025-gold-report/ (accessed 17 November 2025).
3. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Available at: https://ginasthma.org/2024-report/ (accessed 17 November 2025).
4. Department of Health and Human Services (HHS). HHS Framework to Support and Accelerate Smoking Cessation 2024. Available at: https://www.hhs.gov/sites/default/files/hhs-framework-support-accelerate-smoking-cessation-2024.pdf (accessed 17 November 2025).