Nicotine Addiction: treatment perspectives

Tobacco smoking is the leading cause of illness and premature mortality in the world. Nevertheless, in Italy over 11 million adults are still current smokers (21.7% of the entire adult population), and only 27% of these smokers report that they have tried stopping at least once in their lifetime (Doxa-ISS 2012). In the world approximately 5 million deaths annually are tobacco-related (85,000 to 90,000 in Italy), which will become 10 million in 2020, if we keep the current trend. Tobacco smoking has a determinant role in the four most common causes of death in the USA: ischemic heart disease, cancer, cerebrovascular disease, Chronic Obstructive Pulmonary Disease (COPD). Nicotine is included in the DSM IV as an addictive substance and tobacco addiction is considered to be a chronic medical illness. Because many smoking-induced pathologies improve upon cessation, in Italy, in addition to a smoke free legislation introduced in 2005, clinical practice guidelines, as in USA, have been developed to help smokers to quit (OssFAD-ISS, 2008). The guidelines recommend the use of i) pharmacotherapy (nicotine replacement therapy, bupropion, varenicline) and ii) counseling for all quit attempts. Pharmacotherapy and counseling in combination has been found to achieve the highest rate of smoking cessation, in particular pharmacotherapy combined with group counseling improved the rate of continuous smoking abstinence at 1-year follow-up in smokers who wanted to quit (odds ratio: 4.3, 95% CI = 2.1–8.9 (2-4). An intriguig novel therapeutic approach is vaccination against nicotine (NicVAX) that has now entered Phase III clinical trials. Advice and assistance by physicians have an inportant role in helping smokers to quit, in particular, assistance by GPs in advising and motivating smokers to quit, the so-called 'minimal intervention' which aims to create or strengthen motivation to stop. It is rapid and effective and is based on the model of the five "A": Ask, Advice, Assess, Assist, Arrange; studies have shown that receiving advice from a doctor increases the rates of smoking cessation.Finally, recent studies demonstrate that Italian medical students have limited knowledge about tobacco dependence, how to treat it, and the critical role of the physician in promot-ing cessation (5). Taken together with research from other coun¬tries, these findings suggest that, until now, little attention has been paid to the topic of tobacco dependence in the curricula of Italian medical schools accordingly, Italian physicians neither do regularly advise smokers to quit nor do prescribe phar¬macotherapy for tobacco dependence at recommended levels.