Smoking has a huge impact on health care provision, an estimated additional £1.4 billion being spent annually on smoking related diseases in Britain.1 This will continue to rise with the suggested improvements in lung cancer care2 and the estimated increased morbidity due to COPD.3 Helping people to stop smoking will clearly reduce the impact of these and other smoking related diseases, but how is this best achieved? Evidence suggests that advice and support from the primary care doctor to individuals who are contemplating stopping is the simplest and most cost effective method,2 ,4 ,5 though the newly published smoking cessation guidelines6 also describe more intensive interventions. One factor which is, however, crucial to the success of most of the smoking cessation methods available is the opinions, training, and counselling skills of doctors.

The review on medical students’ attitudes and knowledge of tobacco issues by Richmond published in this issue ofThorax is therefore cause for concern.7 In UK medical schools between 11% and 35.7% of students use tobacco daily, while in North America single percentage figures are reported. This contrasts sharply with areas of Poland and Spain where 61% of medical students use tobacco daily. Many students start or increase their use of tobacco as they progress through medical school. The reasons for this are not obvious but may relate to inadequate knowledge of smoking related diseases and peer pressure/role models, not only from qualified doctors and more senior students but from other health care professionals.

Richmond also highlights deficiencies in the teaching of tobacco related diseases and methods of smoking cessation. Few medical schools include smoking related diseases as a distinct topic within the curriculum and the teaching that does occur is usually within the context of lectures on more general respiratory and cardiovascular systems. With the large amount of information to deliver, sufficient time and appropriate content within the curricula are essential. Formal lectures improve knowledge but not the counselling skills required for smoking cessation. More imaginative teaching methods such as role play and small group working probably have a great deal more to offer.

Several teaching programmes using these methods have been developed, although as yet there is little information on the quality of outcomes resulting from this approach. Fundamental to this teaching, however, is the concept of Stages of Change8 which recognises that smokers pass through a cycle of continued tobacco use, pre-contemplation, contemplation, and actual smoking cessation. Advice and support to those considering stopping smoking is more likely to be successful than in those who are not, but this group may also be prepared to consider stopping if asked at a subsequent consultation.

What are the essential messages from the review? The worldwide burden of tobacco related problems will continue to rise as new markets are developed. To minimise the impact of this a series of measures will be necessary, including better programmes for smoking cessation. To be effective these require primary care doctors who are knowledgeable about the problems of smoking and have the appropriate counselling skills. With the current training many medical students will qualify unable to provide such a service. The undergraduate and postgraduate training of smoking related issues needs to be addressed urgently.