TABAGISM

In Italy, 90,000 deaths a year are attributed to smoke. An ex smoker would cut down the risk of tumours in the respiratory and digestive system by 50% after five years, with a reduction of 70% of the risk of bronchial carcinoma after ten years. To this regard, it is important to note that a person who stops smoking by the age of 45 reduces the risk of lung cancer to a level nearly similar to that of patients who never smoked. The former smoker perceives very tangibly a rapid improvement of the respiratory functions, even in cases of advanced and persistent illness. What is particularly encouraging is the rapid disappearance of coughs deriving from contact with irritating gases. The fast disappearance of carbon monoxides brings about an increasing flow of oxygen with rapid advantages in terms of oxygenation and even in terms of aesthetics, which are especially more evident in women.

Coronary risks are reduced by 50% after a year of abstention, equaling the risk level of non-smokers after fifteen years. The risk of ictus is re-aligned with that of non-smokers after 5 to 15 years. In diabetic people who stop smoking there is a sharp reduction of peripheral arteriopathy with a remarkable reduction of all micro-angiopathic complications.

Tobacco is certainly and unmistakably a narcotic, and is difficult to give up for various reasons. When smoked, it rapidly reaches the brain and therefore responds to the most fearsome definition of drugs, especially because of the speed of its psychoactive action. Moreover, cigarettes give smokers the chance to acquire a more efficient drug control with respect to other drugs; this means that the smoker, through a certain number, frequency and intensity of puffs, can perfectly exert self-control according to his/her own psycho-physical demands: taking in more nicotine under nervous conditions (in this case the nicotine will have a relaxing effect) and less but more constant dosages when a stimulating action is needed. Biochemically, the abstinence crisis manifests itself in nicotine-dependent people through a neurohormonal storm provoked by the strong reduction of dopamine at the accumbens nucleus level of the mesocortic-limbic system with the consequential intense stimulation of the prefrontal cortex on the part of the noradrenergic fibers usually inhibited by the dopamine itself. The person’s strong sense of alertness and awareness of danger is immediately deleted by a new assumption of nicotine, provoking an instinctive aversion to re-experiencing the unpleasant sensation. The term “craving” expresses an irresistible desire to take a drug, in this case to smoke.

Simple advice from a doctor, the use of informative material with details regarding the dangers of smoking, along with the support of a group, have proven very important in helping a person stop taking nicotine, but have a limited effect. Because of this, after an attentive study and a correct support system, the doctor should consider the administration of pharmacologic therapies.

The medicine currently used is Bupropion (Amphebutamon), an amphetamine derivate. This product has interesting characteristics: first of all, it is the only medicine which, thanks to its dopaminergic activity, produces an effective anti-craving effect; moreover, like all amphetaminic derivations, it has an anorectic effect, useful in counterbalancing the hyperphagia of the patient who stops smoking, and a stimulating effect capable of fighting the sleepiness which often arises during the first days of abstinence: we can finally add a bland anti-depressive effect.

The medical use of nicotine to stop smoking is still considered the referral treatment by the World Health Organization. In Italy, unlike other countries where the NRT has been and continues to be used, the treatment was rarely and badly implemented, probably due to scarce information given to doctors, and was often self-administered for a few days, or in low dosages, annulling its otherwise undoubted potentials.

Treatment is available in the form of patches to wear on the skin. The strong point of patches is the constant release of nicotine, but this is also the weak point of this treatment: the patient usually tends to smoke during moments of stress when the craving for nicotine is at its peak, whereas the same patient may also feel irritated by the excessive charge of nicotine during moments of relaxation, with signs of irritability, nausea and palpitations. The use of plaster patches is the first choice in cases of patients who have already benefited from a previous treatment, in patients who do not want to use medicines, patients with case histories of bad depression and smokers who smoke a constant number of cigarettes. The patches are not recommendable for smokers with great circadian and weekly differences in the number of cigarettes; chewing gums are more appropriate in this case.

The gums, 2 or 4 mg of nicotine, must be chewed at length (about 30 min.) so that a congruous quantity of nicotine can be absorbed. 4 mg proved more effective than 2 mg. The gums allow patients to vary the nicotinemia in various hours of the day, even though it is recommendable for patients to chew the gum at regular intervals rather than according to their needs, given the slower absorption compared to cigarettes. Gums usually taste unpleasant, but some are flavoured with spearmint. The possible side effects are a burning sensation in the mouth and throat, nausea and hiccups.

The inhalers, which give a small quantity of nicotine in powder form which the patient must continuously inhale to feel some benefits, can prove useful in patients for whom gestures are an important part of dependency. Equally useful are the 2 mgs sublingual nicotine pills in patients with mobile dental work or who do not habitually chew gum; the faster absorption of nicotine compared to chewing gums and inhalers makes this formula ideal for smokers with strong compulsive behaviour.