Smokers who have tried to quit and failed may be tempted to just give up, particularly if they hear statistics like the fact that most quit attempts will be unsuccessful. But smokers today have many options to help them quit, and those who think they have "tried it all" usually have not. In a report in the Oct. 17 issue of JAMA, Nancy Rigotti, MD, director of the Tobacco Research and Treatment Center of the Massachusetts General Hospital (MGH) Department of Medicine, outlines currently available resources and recommends strategies that can help smokers who are struggling to quit.

"Many smokers believe they have tried and failed all treatments because they -- and their physicians -- have not used existing treatments in the most effective way," Rigotti says. "Outdated product labeling by the Food and Drug Administration for nicotine replacement therapy contributes to this problem, as does the fear of possible side effects of FDA-approved medications. As a result, some smokers consider using newer untested and unregulated products like electronic cigarettes."

In her paper, based on a grand rounds presentation at Northwestern University Feinberg School of Medicine, Rigotti presents a hypothetical smoking patient: a 50-year old man who is discouraged because previous quit attempts -- one with nicotine replacement, the other with the antidepressant bupropion (Zyban) -- did not succeed. He is reluctant to try varenicline (Chantix), another FDA-approved smoking cessation medication, because of concern about possible serious side effects. Feeling that he has "tried everything," he asks his physician whether he should consider electronic cigarettes.

Rigotti notes that many quit attempts fail because smokers do not use existing treatments or, like the smoker in the example, don't use them in the most effective way. Only one third of smokers who try to quit use behavioral support or medication -- both of which have been proven to be effective. Even fewer smokers combine both types of assistance, even though this further improves a smoker's chance of success, Like the patient in the example, many may not be aware of the support that is available free through the nationwide toll-free number 1-800-QUIT-NOW.

Smokers who do use nicotine replacement therapy (NRT) may not do so in the most effective way. Though many products are available -- including over-the-counter patches, gums and lozenges and prescription-only inhalers and nasal spray -- many smokers only use one product when studies have shown that combining two is safe and more effective, Rigotti says. The patch provides steady, prolonged relief of nicotine withdrawal symptoms but cannot help with sudden cravings that may be triggered by environmental cues like watching someone light up. Shorter-acting products like gums or lozenges can help smokers handle those cravings. Despite strong evidence that combining NRT products is more effective than using single agents and support for combined therapy in the 2008 U.S. Public Health Service Clinical Practice Guideline, the labels currently approved by the FDA caution smokers not to combine different nicotine replacement products.

Some smokers may be discouraged from using two other FDA-approved smoking cessation drugs, bupropion and varenicline, because of reports of behavioral changes in patients taking those drugs, even though they double a smoker's odds of success when making a quit attempt. Rigotti notes that in any individual it can be difficult to distinguish a side effect from the effects of nicotine withdrawal, which can include nervousness and depression. Stressing that both drugs are among the few effective options for treating tobacco dependence, she notes that physicians and patients need to weigh the small potential risk of side effects against the certain risk of continuing to smoke. In most cases, Rigotti concludes, these drugs' benefits would outweigh their risks, but she that cautions physicians do need to monitor patients who start on these drugs for behavior changes.

Returning to the hypothetical patient she described, Rigotti stresses, "In fact, he has not tried everything," adding that behavioral support, combined nicotine replacement treatment and a more adequate trial of the strategies that he abandoned are all available options. She would particularly recommend this patient try behavioral support to increase his confidence and encourage him to use a quit line or other source of continuing support. Exploring these evidence-based, FDA-approved options would be a better choice for him than electronic cigarettes, the safety and effectiveness of which are unknown.

"Tobacco use kills approximately half of regular smokers, and treatment for tobacco use is one of the most cost-effective actions that physicians and health care systems can take," says Rigotti, a professor of Medicine at Harvard Medical School. "Those of us who provide health care need to recognize tobacco dependence as the chronic condition that it is and give tobacco treatment as high a priority as we do other chronic diseases like diabetes or high blood pressure."

Rigotti adds that long-term management is a better strategy for treating tobacco dependence than expecting that it can be addressed in a single physician visit. Health care systems need to support the necessarily brief stop-smoking advice that primary care physicians can deliver by directly linking patients to resources for continued stop smoking assistance. The national network of state-supported telephone quit lines is one resource that can be utilized to address what continues to be the leading preventable cause of death in this country. Rigotti's work is supported by a grant from the National Heart, Lung and Blood Institute.