Quitting smoking: gains by age and support in each setting

She is 67 years old, has smoked since adolescence and has just been admitted for pneumonia. On rounds, someone on the team remarks quietly that "at this point there is no use asking her to stop". The sentence sounds like common sense and like respect. But the evidence says otherwise: stopping at 60 still adds years of life, and admission is one of the moments when support works best.

This text deals with two questions that fall outside the choice of treatment. The first is how much is gained by stopping at each age and over time after the last cigarette. The second is how evidence-based support changes in concrete scenarios: hospital admission, established cardiovascular disease, cancer diagnosis, pregnancy, mental illness and social inequality. The approach itself, with brief counseling and the choice among treatment options, is in the text on smoking cessation at every visit.

Key points

• Stopping smoking brings benefit at any age; the earlier, the greater the gain.
• Stopping before age 40 avoids most of the excess mortality caused by continuing to smoke.
• After a myocardial infarction, stopping is associated with about one third fewer cardiovascular events.
• During hospital admission, support works when it continues for more than a month after discharge.
• Stopping smoking does not worsen mental health; studies show small to moderate improvement.
• Support that lasts depends on systems, not only on each professional's goodwill.

Summary

• It is never too late: what the large cohorts show by age
• The clock after the last cigarette: gain over time
• Hospital admission as a window
• After myocardial infarction and in established cardiovascular disease
• After a cancer diagnosis
• Pregnancy, mental illness and social inequality
• Support that lasts: systems in primary care and long-term maintenance
• Reasoning errors about who "has no point stopping anymore"
• Frequently asked questions
• Final checklist

It is never too late: what the large cohorts show by age

The idea that stopping late "is not worth it" rests on an intuition: the damage would already be done. The large cohorts show that part of the damage is indeed done, but that the other part depends on continuing to smoke, and that part can be avoided.

The Surgeon General report dedicated to cessation summarized the evidence in two main conclusions: stopping smoking is beneficial at any age, improves health status and quality of life, and reduces the risk of premature death, and can add up to a decade to life expectancy (US Department of Health and Human Services, 2020). The same report concluded that stopping reduces the risk of cardiovascular disease, COPD, cancer and adverse reproductive outcomes, and that it also brings benefit to those who already have heart disease or COPD (US Department of Health and Human Services, 2020).

The numbers by age come from very large cohorts. In a cohort of 34439 physicians followed for 50 years, stopping at 60, 50, 40 or 30 years of age added, respectively, about 3, 6, 9 or 10 years of life expectancy compared with continuing to smoke (Doll and colleagues, 2004). In a national survey that followed 113752 women and 88496 men, the risk of death from any cause among smokers was about three times that of never-smokers, with hazard ratios of 3.0 in women and 2.8 in men (Jha and colleagues, 2013). In that same population, those who stopped between 25 and 34 years, between 35 and 44 years or between 45 and 54 years gained about 10, 9 and 6 years of life compared with those who continued (Jha and colleagues, 2013).

Among women, a cohort with more than one million participants showed the same pattern. Those who were smoking at the start of the study had a 12-year risk of death 2.76 times that of never-smokers (Pirie and colleagues, 2013). Among those who stopped for good, the relative risk of death was 1.05 for those who stopped between 25 and 34 years and 1.20 for those who stopped between 35 and 44 years (Pirie and colleagues, 2013). The authors concluded that stopping before age 40 avoids more than nine tenths of the excess mortality caused by continuing to smoke, and that stopping before 30 avoids more than 97 out of every 100 parts of that excess (Pirie and colleagues, 2013).

Two readings fit here at the same time. Stopping early is much better than stopping late, and that should come up in conversations with young people. But stopping late is still worth it, and withholding that information from a 60-year-old person is denying them one of the biggest health gains available. The risk does not disappear, but it stops growing.

The clock after the last cigarette: gains over time

Beyond age, the time since the person stopped matters. The benefit does not appear all at once, and each outcome has its own pace. The table below organizes what the cohorts and reviews cited show, without claiming to set exact timelines for each person.

Age at stopping or time since stopping	What the cohorts and reviews show
Stopping before age 30	Avoids almost all of the excess mortality of continuing to smoke (Pirie et al., 2013)
Stopping between ages 30 and 40	Gain of about 9 to 10 years of life compared with continuing (Doll et al., 2004)
Stopping between ages 45 and 54	Gain of about 6 years of life (Jha et al., 2013)
Stopping around age 60	Gain of about 3 years of life (Doll et al., 2004)
Stopping after a coronary event	Less cardiovascular death and fewer new events compared with continuing (Wu et al., 2022)
Stopping after lung cancer	Lower incidence of a second primary lung cancer during follow-up (Luo et al., 2021)
Long-term former smokers	Some excess risk persists, especially for lung cancer, but much lower than for those who continue (Pirie et al., 2013)

The last row deserves attention. Among women who stopped between ages 35 and 44, the relative risk of death from lung cancer was still 3.34 compared with those who never smoked (Pirie et al., 2013). Former smoker is not a synonym for zero risk. This matters for clinical surveillance of respiratory symptoms and for reasoning in the face of imaging findings, even many years after the last cigarette.

The time since the person stopped also helps interpret the history. "Former smoker" can mean two weeks or thirty years, and the two cases have very different prognoses. Recording the date the person stopped, and not just the label, is a detail that changes the risk estimate in future visits.

Hospitalization as a window

Hospitalization brings together rare conditions. The person is away from triggers at home, often cannot smoke in the hospital, and the illness that brought them in usually makes concrete the risk that once seemed abstract. Studies show that this window can be used, as long as the support does not end at discharge.

A systematic review of 33 trials showed that counseling started during hospitalization and maintained with support contacts for more than a month after discharge increased cessation at 6 to 12 months, with an odds ratio of 1.65 (Rigotti et al., 2008). There was no benefit with interventions with less contact after discharge, and counseling worked both for all hospitalized smokers and for the subgroup hospitalized for cardiovascular disease (Rigotti et al., 2008).

The updated review, with 50 trials, confirmed the pattern: intensive interventions that began during hospitalization and continued for at least a month after discharge increased cessation, with a relative risk of 1.37 (Rigotti et al., 2012). In the subgroup hospitalized for cardiovascular disease, the relative risk was 1.42, and in rehabilitation hospitals it was 1.71 (Rigotti et al., 2012). The authors concluded that the effect is independent of the diagnosis that led to hospitalization and that there is no evidence of effect for lower-intensity or shorter interventions (Rigotti et al., 2012). It is worth flagging the conflict of interest declared in both versions: the first author reports research also funded by pharmaceutical companies that make cessation products and was a coauthor of three included studies (Rigotti et al., 2012).

The lesson for practice is about care design, not talk. A conversation on the eve of discharge, with no follow-up, is the intervention that studies show does not work. What works is combining the start in the hospital with a concrete plan for contact after discharge: phone calls, a scheduled follow-up visit or a referral to a service that takes on the follow-up. In the patient from the opening scene, the team's sentence is the opposite of what the evidence recommends.

There is also a bias to watch for. When faced with a person admitted for another cause, smoking tends to disappear from the problem list, overshadowed by the main diagnosis. When a label such as "elderly", "frail" or "uncooperative" starts to explain everything, other problems stop being seen, in a mechanism similar to the one described in the text about diagnostic overshadowing.

After myocardial infarction and in established cardiovascular disease

In secondary prevention, the question changes. It is no longer about preventing the first disease, but about reducing the chance of a new event in a person who already has coronary disease. The evidence here is especially relevant, because the person is in frequent contact with the health system and the risk of a new event is high.

A systematic review of 68 studies, with 80702 participants with coronary disease who smoked at diagnosis, compared those who quit with those who kept smoking (Wu et al., 2022). Quitting was associated with a lower risk of cardiovascular death, with a hazard ratio of 0.61, and of major cardiovascular events, with a hazard ratio of 0.57 (Wu et al., 2022). The hazard ratio for death from any cause was 0.60 (Wu et al., 2022). The authors concluded, with moderate certainty, that quitting at diagnosis is associated with a reduction of about one third in the risk of recurrent cardiovascular disease, and that quitting did not worsen quality of life (Wu et al., 2022).

The data come from observational studies, and the authors themselves point out the risk of confounding: people who quit smoking may also adhere better to other secondary prevention measures (Wu et al., 2022). Even so, the association is consistent and has biological plausibility, since the authors recall the recovery of endothelial and platelet function after quitting (Wu et al., 2022).

In practice, the patient after myocardial infarction usually leaves the hospital with a long list of medications and targets. Cigarettes can stay hidden among them, treated as generic lifestyle advice. Organizing priorities together with the person, as discussed in the text about priorities in a consultation with many complaints, helps put tobacco in the place the evidence indicates: among the measures with the greatest impact.

After a cancer diagnosis

A cancer diagnosis usually leads to two opposite reactions in the team. One is to think that, faced with a serious disease, quitting smoking has lost importance. The other is to treat cigarettes as blame. Neither of the two helps the person.

The data suggest that diagnosis is a moment when many people quit, and that quitting still makes a difference. In a cohort of 986 smokers who later received a lung cancer diagnosis, those diagnosed in the interval between the two assessments had a much higher chance of having quit, with an adjusted odds ratio of 5.12 (Luo et al., 2021). Among participants who quit, the incidence of a second primary lung cancer was lower, with an adjusted hazard ratio of 0.31 compared with those who kept smoking (Luo et al., 2021). The authors concluded that quitting after diagnosis may reduce the risk of a new cancer in the lungs (Luo et al., 2021).

The full text of the cohort makes the limitations clear: all exposure data were self-reported, subject to recall bias, and smoking was assessed at only two points, at baseline and ten years later (Luo et al., 2021). The result should be read as an association, not as a precise estimate of effect. The Surgeon General report, in turn, includes lung cancer among the cancers whose risk is reduced by quitting (US Department of Health and Human Services, 2020).

In cancer care, support for cessation fits into the team's routine. When the diagnosis brings in several professionals from the start, as the text on the multidisciplinary team in lung cancer describes, someone needs to explicitly take on the conversation about smoking. And when age and comorbidities enter the decision about treatment, smoking is one of the variables that can still change, as the text on age, comorbidity and patient decision discusses.

Pregnancy, mental illness and social inequality

Three scenarios account for a large part of the smoking that persists and require specific attention.

Pregnancy

In pregnancy, the benefit reaches two people, and psychosocial support has good-quality evidence. A systematic review included 102 trials on psychosocial interventions to help pregnant women stop (Chamberlain et al., 2017). Counseling increased cessation at the end of pregnancy compared with usual care, with a pooled relative risk of 1.44, in high-quality evidence (Chamberlain et al., 2017). Women who received psychosocial interventions had fewer low-birth-weight newborns and a mean birth weight 55.60 g higher (Chamberlain et al., 2017). The authors found no adverse psychological effects of the interventions (Chamberlain et al., 2017).

Mental illness

In mental illness, the belief that cigarettes "calm" and that stopping will destabilize the person is one of the biggest obstacles to offering support. A meta-analysis of 26 observational studies compared the change in mental health of those who stopped with that of those who kept smoking (Taylor et al., 2014). Anxiety, depression and stress decreased more in those who stopped, with standardized mean differences of -0.37, -0.25 and -0.27 (Taylor et al., 2014). The effect was similar in people with and without psychiatric disorders (Taylor et al., 2014). In the conflict of interest statement, one of the authors reports fees from manufacturers of cessation products, outside the published work (Taylor et al., 2014).

The later Cochrane review expanded the base to 102 studies and more than 169500 participants (Taylor et al., 2021). Stopping was associated with improvement in depression symptoms, with a standardized mean difference of -0.30, and in anxiety, with -0.28 (Taylor et al., 2021). The authors concluded that mental health does not worsen when people stop smoking and that there is evidence of very low to moderate certainty of small to moderate improvement, including in people diagnosed with a mental disorder (Taylor et al., 2021). All studies were considered at serious risk of bias from time-varying confounding, which limits certainty (Taylor et al., 2021).

Social inequality

Smoking is concentrated in groups of lower socioeconomic status, and these people are less likely to manage to stop. A Cochrane review gathered 77 studies with 127791 participants to find out whether individual interventions work differently according to socioeconomic status (Theodoulou et al., 2025). The conclusion was that there is no clear evidence to recommend different individual interventions for people of lower or higher socioeconomic status, nor that any specific intervention reduces inequalities (Theodoulou et al., 2025). The authors note that many studies do not report results by socioeconomic status and ask that this be done from now on (Theodoulou et al., 2025).

In practice, the absence of differences between interventions does not mean that context does not matter. It means that support already proven to work should reach everyone, and that access barriers weigh more than the choice of technique. It is also worth watching one's own judgment: assuming that a person who is poor, older or has a mental disorder "won't manage" is a bias that reduces the offer of help, as the text on age and implicit bias in diagnosis discusses.

Support that lasts: primary care systems and long-term maintenance

Most people who smoke pass through primary care. The question there is not only what to say in a consultation, but how to organize the service so that support happens every time and continues.

A Cochrane review gathered 81 trials with 112159 participants to assess strategies that improve cessation in primary care (Lindson and colleagues, 2021). With moderate certainty, three strategies increased cessation: additional counseling by another health professional besides the physician, with a relative risk of 1.31; cessation medication at no cost to the person, with 1.36; and tailored printed material, with 1.29 (Lindson and colleagues, 2021). There was no clear evidence that training the professionals increased cessation, with a relative risk of 1.10, although there are signs that training increases the offer of support (Lindson and colleagues, 2021). The review notes that one of the authors works at an institute that received funds from the pharmaceutical industry (Lindson and colleagues, 2021).

The reading of this result is systemic. The gain came from adding people, access and material to the care, not from asking more of a single professional. A service that records smoking status, has somewhere to refer people and reduces cost barriers tends to offer more support than a service that depends on each physician remembering.

Maintenance is the other half. A Cochrane review of 81 studies with 69094 participants assessed interventions to prevent relapse (Livingstone-Banks and colleagues, 2019). Behavioral interventions that teach people to recognize risk situations and cope with them brought no relevant benefit in those who had already quit with help, and the results with extended pharmacological treatment were mixed (Livingstone-Banks and colleagues, 2019). One of the authors declares consultancy for manufacturers of cessation medications (Livingstone-Banks and colleagues, 2019). How to handle relapse in the consultation, and what it teaches about the plan, is in the text about relapse as clinical data.

Reasoning errors about who "it is no longer worth quitting"

The previous scenarios show that the evidence favors offering support in almost every situation. Why, then, do so many people fail to receive this offer? Part of the answer lies in recurring reasoning errors.

"It is too late." Advanced age seems to make the benefit irrelevant. The cohorts show a gain in years of life even when quitting around age 60, and the Surgeon General concludes that quitting is beneficial at any age (US Department of Health and Human Services, 2020).

"The damage is already done." After a heart attack or a cancer, quitting seems useless. It is precisely in these groups that studies show fewer recurrent events and fewer second cancers in those who quit.

"Now is not the time." During hospitalization, a serious diagnosis or a mental health crisis, postponing the conversation seems kind. Hospitalization is one of the most effective windows, and the data do not show worsening mental health after quitting.

"This person will not manage it." Labels about motivation, social level or psychiatric diagnosis reduce the offer of help without basis in the evidence. Listening to what the person says about change, as proposed in the text about change talk in motivational interviewing, is more useful than predicting failure.

"Either quit for good, or it is all for nothing." All-or-nothing thinking leads to ending the conversation when the person does not accept quitting right away. Keeping the bond and returning to the topic in other consultations is part of the care, as discussed in the text about all-or-nothing thinking as a bias.

These errors have something in common: they replace the evidence with a prediction about the person. The correction is simple to state and hard to do: offer support to everyone, adapt the format to the scenario and pay attention to the cues the person gives in the conversation, as shown in the text about cues the patient offers. For the brief approach itself, the script is in the text about brief counseling.

Frequently asked questions

Is it worth quitting smoking after age 60?

Yes. In a cohort followed for 50 years, quitting around age 60 added about 3 years of life expectancy compared with continuing to smoke (Doll and colleagues, 2004).

Does quitting after a heart attack change the prognosis?

Yes. In a review of 68 studies with people who have coronary disease, stopping was linked to about a third less risk of recurrent cardiovascular disease (Wu et al., 2022).

Does stopping after a cancer diagnosis still make a difference?

The data suggest it does. In a cohort, those who stopped after a lung cancer diagnosis had a lower incidence of a second primary lung cancer (Luo et al., 2021).

Does stopping smoking make mental health worse?

The studies indicate the opposite. A Cochrane review concluded that mental health does not get worse when stopping and that there is a small to moderate improvement, including in people with mental disorders (Taylor et al., 2021).

Why is a hospital stay a good moment to offer support?

Because the person is away from the usual triggers and the illness makes the risk concrete. Support started in the hospital works when it continues for at least a month after discharge (Rigotti et al., 2012).

Does this text guide treatment?

This text covers the benefit of stopping and how support is organized. The choice of treatment depends on individual assessment and current guidelines, and is discussed in another blog text.

Final checklist

• Offer support to stop at any age, including after 60.
• Record the date the person stopped, not just the ex-smoker label.
• Use the hospital stay as a window and ensure support contact after discharge.
• Put smoking among the priorities of secondary cardiovascular prevention.
• Include cessation in the oncology team's plan from diagnosis onward.
• In pregnancy, offer structured psychosocial support.
• Remember that stopping does not make mental health worse and offer support also to those with a mental disorder.
• Be wary of predictions like "this person won't manage".
• Think in terms of a system: another professional, free access, materials and a scheduled follow-up.

References

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