Quitting smoking: the most effective step – and the methods that actually work

For anyone who smokes, nothing else they could do for their health comes close to quitting. No screening test and no medication gives back as many years of life – at any age. Yet most smokers try on their own, relying on willpower. That so many fail reflects addiction, not weak character. But several methods have proven effectiveness from dozens of randomised trials – and since August 2025, Germany's statutory health insurance pays for some of them.

What quitting gives back in years of life

In the British Doctors Study, Richard Doll and Richard Peto followed more than 34,000 male British doctors from 1951 for 50 years. Those who kept smoking died on average about ten years earlier than lifelong non-smokers. Quitting at 30 gained back about 10 years of life expectancy, at 40 about 9, at 50 about 6 and at 60 still about 3. A US analysis of more than 200,000 adults (Jha et al., 2013) found almost the same; quitting before 40 avoids about 90% of the excess risk of death.

According to the US Centers for Disease Control and Prevention (CDC), heart-attack risk drops sharply within one to two years; the added risk of lung cancer halves after 10 to 15 years. In Germany, the 2025 Tobacco Atlas of the German Cancer Research Center (DKFZ) attributes about 131,000 deaths in 2023 to smoking – 13.7% of all deaths. More than one in four adults smokes.

Why willpower alone rarely works

Without nicotine, withdrawal sets in: irritability, restlessness, low mood, hunger and strong cravings. According to the US National Cancer Institute, symptoms are worst in the first week, peaking in the first three days, and ease considerably over the first month. Of people who quit without any help, only 3–5% are still abstinent six to twelve months later. Help improves those odds considerably.

What works

Cochrane has systematically pooled the evidence; the figures refer to abstinence after at least six months. A relative risk (RR) of 1.5 means 50% more successes than in the comparison group; the absolute gain depends on the starting rate (see absolute vs relative risk).

• Counselling and behavioural support: increase the chance by about 44% (odds ratio 1.44; 194 studies; high certainty), with or without medication. On top of a drug, support adds about another 15% (RR 1.15).
• Nicotine replacement therapy (NRT): RR 1.55 (133 studies, more than 64,000 participants; high certainty). Combining a patch with a fast-acting product (gum, lozenge, spray) beats a single form (RR 1.27; high certainty).
• Varenicline (prescription) dampens craving and reward: RR 2.32 versus placebo (41 studies, more than 17,000 participants; high certainty), better than bupropion (RR 1.36) and single-form NRT (RR 1.25), roughly equal to combination NRT (RR 1.02). In a registration trial with 1,025 participants, 21.9% on varenicline were continuously abstinent from week 9 to 52, versus 8.4% on placebo – about 13 extra successes per 100 treated. The EAGLES trial (more than 8,000 participants, including people with mental illness) did not confirm fears of psychiatric side effects.
• Cytisine, a plant compound from laburnum, works similarly: RR 1.30 versus placebo (moderate certainty), with no clear difference from varenicline head to head. In Germany it has been available on prescription since 2020 but is self-pay; the S3 guideline lists it as an option when other therapies have failed.
• Bupropion, an antidepressant: RR 1.60 (high certainty), but more often stopped because of side effects.

Germany's S3 guideline on smoking and tobacco dependence (AWMF 076-006, 2021 version; S3 is the highest-quality tier of German guidelines) gives its strongest grade (A) to behavioural therapy, telephone counselling, varenicline, bupropion and – where a single form is not enough – combination NRT, and to combining medication with a cessation programme. That combination offers the best odds.

E-cigarettes: helpful, but no free pass

Cochrane's continuously updated review, in its August 2026 version, includes 80 randomised trials with almost 30,000 participants. Nicotine e-cigarettes lead to quitting more often than NRT (RR 1.61; high certainty) – about 4 extra quitters per 100 people (range 1 to 7). Serious adverse events were rare and similar to NRT.

But long-term safety is unknown, and the data apply only to regulated nicotine products. What counts is switching completely: someone who keeps smoking while also vaping ("dual use") has not quit. The 2021 S3 guideline, which predates much of this evidence, considers the data on cessation inconsistent and, by expert consensus, advises against offering e-cigarettes merely to cut down; the German Society of Addiction Medicine, in a dissenting vote, would consider them when other options are unsuitable. For heated tobacco products, Cochrane found not a single study measuring cessation. Anyone who does not smoke should not start vaping.

What is covered in Germany

Since 20 August 2025, statutory health insurance (GKV, covering most people in Germany) pays for NRT and varenicline, following a decision of the Federal Joint Committee (G-BA, the body that defines what statutory insurers cover) of 15 May 2025. Conditions: severe tobacco dependence (diagnosis F17.2 and at least 6 points on the Fagerström test, or a failed quit attempt despite a condition such as COPD, asthma or cardiovascular disease, or during pregnancy) and participation in an evidence-based programme, such as a certified course or a listed digital health app (DiGA). One course of treatment is covered, reviewed after three months; a new entitlement arises after three years at the earliest. Nicotine and varenicline may not be combined; cytisine and bupropion remain self-pay.

Many insurers subsidise certified quit-smoking courses, usually with at least 80% attendance. Free of charge are the Rauchfrei-Telefon helpline of the Federal Institute for Public Health (BIÖG, formerly BZgA) on 0800 8 31 31 31 and the three-week online programme at rauchfrei-info.de.

For long-term heavy smokers: since April 2026, people aged 50 to 75 with at least 25 years of smoking and 15 pack-years, who still smoke or quit less than ten years ago, are entitled to annual low-dose CT lung screening. Men from 65 can have abdominal aortic aneurysm screening – smoking is the most important modifiable risk factor. And quitting lowers the calculated cardiovascular risk that also informs whether a statin makes sense.

Weight, withdrawal and relapse

On average, people gain 4–5 kg in the twelve months after quitting, mostly in the first three; about 16% lose weight and about 13% gain more than 10 kg. The health gain far outweighs it. Relapse is not failure but a normal part of the process – it often takes several attempts.

What this means for you: a six-step plan

1. Set a quit day – a specific date in the near future.
2. Talk to your GP – have your dependence assessed, choose a medication, check insurance cover.
3. Line up support – a course, the Rauchfrei-Telefon or the online programme, ideally before quit day.
4. Use medication properly – varenicline, or a patch plus fast-acting nicotine, at an adequate dose and for as long as prescribed.
5. Plan for triggers – coffee, alcohol, stress: have an alternative for each.
6. Keep going after a slip – and strengthen the help next time. If nothing else has worked, raise a complete switch to a nicotine e-cigarette openly.

This article is general information and not individual medical advice. Decisions about tests and treatment belong in a conversation with your own physician.