Everyone knows how bad smoking is for your health, particularly if you already have respiratory disease. Governments have developed smoking bans, as well as other legislation intended to discourage the habit, and levied so-called "sin taxes" on tobacco products to discourage it. But where are doctors in this discussion?

Physicians can be doing a lot more to help their patients who smoke quit, by connecting them with resources to quit smoking, a recent review of the literature says.

According to a national survey, only about half of all smokers who saw a doctor in the last year recall that they were advised to quit as part of their exam.

Nancy Rigotti, the author of the review, looked at the statistics on quitting smoking among people with respiratory disease. She told TheDoctor that the goal of the issue was to remind doctors that smoking is particularly damaging to those with respiratory diseases, and that quitting has clear benefits, even after chronic disease has started.

One would think that questions about smoking would already be a part of a routine health assessment, but according to Rigotti, a professor of medicine at Harvard Medical School, that is not necessarily the case. “I think that by and large, people are asked about smoking, but their health care providers are not necessarily taking the next step of advising them to quit and helping them to be connected to treatment.”

According to a national survey, only about half of all smokers who saw a doctor in the last year recall that they were advised to quit as part of their exam. Even fewer said that their physician or nurse practitioner had given them any assistance or helped them, because, “I think many doctors do not know a lot about this area, and have tended to neglect it over the years, ” Rigotti said.

Currently, there are two smoking cessation options considered effective: medications to help people deal with nicotine addiction (such as patches or gum), and counseling to provide support and help people as they break the habit.

The most accessible counseling is available through telephone quit lines, which have a counselor call people on a schedule to help them as they go through the process of quitting smoking. These lines are now available for free throughout the U.S. at 1-800-QUIT-NOW, and are designed for those who are ready to quit in the next month or so.

One of the goals of the review was to make people aware of this resource and encourage physicians to suggest that their patients call the quit line.

Nicotine replacement products, bupropion (brand names: Zyban, Wellbutrin), and varenicline (brand name: Chantix) are currently approved for smoking cessation by the U.S. FDA. All of them are effective and can double the chances of success if used by those trying to quit smoking. There are possible side effects, however, making it all the more important that a doctor is part of the process.

A Combined Approach
There are new, more effective ways to use nicotine replacement products. Originally, these products would often be given out individually, and people would, for example, either put on a patch or chew gum. Now we know that if the patch is used together with another shorter-acting nicotine replacement product, like the lozenge, mini-lozenge, gum or inhaler, that combination increases the smokers' rate of success at quitting smoking.

“Using a combination of different types of nicotine replacement products gives people get an adequate dose of nicotine, so they do not get cravings for cigarettes, ” says Rigotti. Many physicians and their patients have not tried this approach, and it is something she has tried to encourage.

Nicotine vaccines are one idea that scientists are currently working on. People would be vaccinated to develop antibodies to nicotine; when they smoked, these antibodies would bind to the nicotine molecules in the tobacco smoke, making them too large to get into the brain, depriving the smoker of the rewards of smoking.

Unfortunately, at the moment, the vaccines that have been tested have not been effective. Such a vaccine will not be available for a long time, and, said Rigotti, “I do not think that people should wait to quit smoking until it becomes available, since we have effective medicines now.”

Published as part of a series on the global tobacco epidemic, the review is available in Lancet: Respiratory Medicine.