The truth about why you can’t quit smoking

I was born at a time when cigarette advertisements were still legal, though as a young boy, my world revolved purely around football and cartoons. Cigarettes meant nothing to me then, and my only real experience was through an uncle who smoked.

When he visited, he would have a thick glass ashtray by his bed, half-filled with ash. There was also a smell that lingered in his room; it did not assault the senses but simply announced itself and stayed. I did not yet recognize it as the smell of cigarettes, and I never actually saw him smoke, perhaps sparing me from his wanton ways.

Next to the ashtray, he kept a pack of gum or menthol sweets, and he would play the guitar as I lay on his bed, swinging my feet and chewing on the sweets. I only realized much later that the sweets and gum were meant to mask the odor on his breath.

I first heard about the negative effects of smoking in high school but it did not really hit home. None of my friends smoked, at least not then. The effects sounded frightening — heart disease, lung disease, hypertension, cancer — but they felt distant and abstract.

By the time I got to medical school, the effects of chronic tobacco use were no longer abstract. In the medical and surgical wards, many patients had long histories of smoking. We were taught to calculate pack years: the number of packs smoked per day multiplied by the number of years one had smoked at that rate. The higher the pack years, the greater the likelihood of harm, or so we were taught.

Many of these patients went on to suffer illnesses clearly linked to smoking, and some eventually succumbed to them. Yet while admitted to the wards, you would sometimes hear stories of how they snuck off to the bathrooms at night to smoke. Where they got the cigarettes from was a mystery to me. Why they felt the need to smoke when they were too ill to go home was even more puzzling.

At the time, I knew the word addiction, but it did not quite register.

My first post was in a remote region, a semi-arid area with a small hospital. Three doctors managed everything from the labor ward to diabetic clinics, administrative duties, and the inevitable interference of local politicians.

It was in the outpatient chronic disease clinics, however, that the questions which would later shape my medical interests began to crystallize.

Many of the patients, particularly the men, were often introduced to the consultation by the acrid smell of tar and nicotine that clung to their clothes. By then, I knew the smell well.

At some point during each visit, we would talk about lifestyle change, and tobacco use would inevitably come up. Many denied smoking outright. With further probing, they would admit to it but insist they had reduced significantly, a claim that was often immediately refuted by whoever had accompanied them.

This confused me. Some of these men had travelled long distances to attend the clinic. Why would they come all that way only to misinform me? Even more puzzling was why they continued to do the very thing that was making them ill.

Cigarettes are a by-product of the curing process of the tobacco plant and became a mass-market, socially acceptable way of promoting tobacco use when compared to traditional chewing and spitting. When tobacco is burned or chewed, nicotine is released into the bloodstream. It is nicotine that drives tobacco use.

Nicotine is among the most addictive substances known. Outside of humans, very few species interact with the tobacco plant, and those that do are often highly specialized and capable of neutralizing its toxic components. Humans are not. Nicotine is toxic and, in sufficient amounts, fatal to many animal species.

What clinicians know without understanding

It was only later, when I began to take a deeper interest in addiction, that I understood why those greying men kept smoking, came to the clinic, and denied it even after repeated counselling. It was not that they had not thought about stopping or did not want to stop. It was that stopping was far harder than I had appreciated.

Many people know that nicotine is addictive. It is usually only users, however, who understand just how powerful that addiction can be and how often the fight to quit is lost daily. Attempts to stop are common, but relapse is frequent and often occurs within days.

“Quitting smoking is easy,” Mark Twain once remarked. “I know because I’ve done it thousands of times.” The humor masks a difficult truth.

Most smokers try to quit repeatedly before they succeed. For many, this means that an intention to stop in early adulthood can stretch into decades of continued use, despite awareness of harm and repeated efforts to quit.

This was not emphasized strongly enough during my training, and it explains why I struggled to understand those greying men and why I often missed opportunities to link them to appropriate support.

Where does tobacco control fit into all this

In 2003, the World Health Organization ratified the first global public health treaty, the Framework Convention on Tobacco Control. The scale of harm caused by tobacco use and nicotine dependence made coordinated global action unavoidable. Countries were urged to adopt strategies to reduce both the demand for and supply of tobacco products.

Article 14 of the Framework specifically calls on countries to promote tobacco cessation and provide treatment for tobacco dependence, recognizing that people who are addicted rarely succeed without structured support. This recognition matters, particularly given that a substantial proportion of long-term smokers will die from smoking-related complications.

Despite this, access to cessation support remains limited. While many tobacco users express a desire to quit, most do not have access to services designed to help them do so.

In Kenya, a 2022 study reflected this gap, finding that while most users wished to quit, many were unsure where such services could be found. The study did not assess whether existing services were adequately resourced or capable of managing nicotine dependence effectively.

Across Africa, only a small number of countries have formally integrated the diagnosis and treatment of tobacco dependence into public healthcare systems, regardless of the quality or reach of those services.

Tobacco dependence is costly for users and for those around them. For smokers, rising taxes make cigarettes increasingly expensive, smoking is stigmatized, and the cycle of sneaking away to smoke and masking the smell becomes exhausting. Added to this are frequent respiratory infections, reduced productivity, and poor long-term health outcomes. For those exposed to second-hand smoke, the consequences can be just as severe.

Many African countries have taken important steps under the Framework Convention to prevent new users from starting. Equally important, however, are those who already use tobacco and have tried, often repeatedly, to stop without success. The burden of smoking-related illness and death falls disproportionately on low- and middle-income countries, placing immense strain on health systems and communities alike.

Is there hope?

I think of the men I met in those clinics, and I understand now that knowledge alone is never enough. Addiction is a daily struggle, one that many face silently. Training health workers to recognize and manage nicotine dependence, improving access to psychological support, and ensuring the availability of effective medications are not just policy measures — they are lifelines for people trapped in addiction.

With the right support, many more could finally break free from nicotine’s grip, and public health in Africa could take a meaningful step forward. For me, seeing that possibility makes every effort worthwhile.