Can it be ethical to apply limited resources in low-income countries to ineffective, low-reach smoking cessation strategies? A reply to Bitton and Eyal

Bitton and Eyal's lengthy critique of our article on unassisted cessation was premised on several straw-man arguments. These are corrected in our reply. It also confused the key concepts of efficacy and effectiveness in assessing the impact of cessation interventions and policies in real-world settings; ignored any consideration of reach (cost, consumer acceptability and accessibility) and failed to consider that clinical cessation interventions which fail more than they succeed also may 'harm' smokers by reducing agency. Our article addresses each of these problems, concluding that any consideration of the ethics of promoting smoking cessation in low-income nations should begin and end with the question of whether the strategies to be adopted have any prospect of influencing significant numbers of smokers to quit.