ABSTRACT

Tobacco smoking remains one of the leading preventable causes of disease, disability and mortality in Italy and worldwide. However, the phenomenon is undergoing a profound epidemiological and cultural transformation that requires a revision of traditional prevention and treatment strategies.

It is no longer sufficient to monitor only the consumption of combustible cigarettes. Exposure to nicotine is increasingly mediated by a plurality of products, including electronic cigarettes, heated tobacco products and nicotine pouches, often used concomitantly.

The data presented at the XXVIII National Conference “Tobacco Smoking and the National Health Service” 2026 (PDF file) show a progressive reduction in exclusive use of conventional cigarettes, but also substantial persistence of nicotine exposure and of patterns compatible with the maintenance of nicotine dependence in the population. This persistence is favoured by the spread of new products and by the growing phenomenon of poly-use. Scientific contributions based on PASSI and PASSI d’Argento surveillance, student surveys among 11-17-year-olds, toxicological data from the Milan Poison Control Centre, evidence on respiratory and cardiovascular risks, and the experience of Smoking Cessation Centres, Regions and the Italian League Against Cancer (LILT) outline a complex and continuously evolving scenario.

The picture that emerges confirms that the reduction in combustible cigarette use is an important public-health achievement, but it does not automatically correspond to a reduction in nicotine dependence or to the elimination of related health risks. For this reason, strategies to address tobacco smoking must be strengthened and modernised through an integrated approach including early prevention, protection of living environments, restrictions on minors’ access to nicotine-containing products, regulation of commercial appeal and clinical management of people who smoke or use nicotine products.

SIPaD PROPOSALS

From this perspective, it is a priority to strengthen the network of Smoking Cessation Centres throughout the country, increasing their number, ensuring a more homogeneous distribution across different areas of Italy and reinforcing multidisciplinary staffing through the inclusion of physicians, psychologists, nurses and other dedicated professionals.

Access to cessation programmes should become simpler, faster and more equitable, allowing a growing number of smokers to benefit from evidence-based interventions.

At the same time, within structured and personalised therapeutic pathways delivered by Smoking Cessation Centres, harm-reduction strategies may be integrated for smokers who are unable or unwilling to stop nicotine use immediately. Such interventions should be embedded in clinical programmes whose primary aim remains complete cessation of smoking, with the goals of reducing exposure to combustion products, limiting related health damage and progressively supporting the abandonment of any form of dependence.

The public-health response should therefore evolve towards a multidimensional model integrating prevention, treatment, harm reduction, epidemiological monitoring and outcome evaluation, while maintaining as its ultimate objective the reduction of morbidity and mortality attributable to tobacco use and to the nicotine dependence that sustains continued use.

1. INTRODUCTION

Tobacco smoking remains one of the main preventable risk factors for cardiovascular, respiratory and oncological diseases. In recent years, however, the tobacco epidemic has changed shape. The conventional cigarette is no longer the only indicator that must be monitored. Alongside combustible smoking, electronic cigarettes, heated tobacco products and nicotine pouches have become established. The real object of analysis is therefore no longer only “who smokes”, but how much nicotine circulates, through which products and in which population groups.

The XXVIII National Conference “Tobacco Smoking and the National Health Service”, held at the Italian National Institute of Health on the occasion of World No Tobacco Day 2026, is located precisely within this transition. The 2026 theme indicated by the World Health Organization, “Unmasking the appeal – countering nicotine and tobacco addiction”, highlights the need to expose the commercial appeal of new products and to counter tobacco and nicotine dependence, especially among adolescents and young adults.

The aim of this article is to reconstruct, with a critical perspective, the transformation of tobacco and nicotine consumption in Italy. The work integrates data on the adult population, evidence on the student population, clinical contributions on the risks of new products, toxicological surveillance, cessation and the role of territorial services. The guiding argument is clear: the decline in conventional cigarette use is a positive signal, but it is no longer sufficient to describe the phenomenon.

2. SOURCES, METHODS AND SCOPE OF THE ANALYSIS

This work is based on the data disseminated by the Italian National Institute of Health on 29 May 2026, on the occasion of World No Tobacco Day and the XXVIII National Conference “Tobacco Smoking and the National Health Service”. The official conference programme, institutional pages of ISS, EpiCentro, the Ministry of Health, WHO, Cochrane, the Official Gazette, LILT and other authoritative scientific or institutional sources were considered.

For the adult population, the main reference is the PASSI surveillance system; for the population aged 65 and over, the reference is PASSI d’Argento. For the student population, the primary source was the recording of the presentation by L. Mastrobattista, National Centre on Addiction and Doping, devoted to tobacco and nicotine use among students aged 11-13 and 14-17 years.

Specialist presentations were also integrated: the pneumological contribution by Boffi, the paediatric-respiratory contribution by La Grutta/SIMRI, the observational analysis by the Milan/Niguarda Poison Control Centre, the presentation by Gallus on cessation, the ISS census of Smoking Cessation Centres presented by Mortali, the analysis by Salvini on regional contexts and the contribution of LILT.

The recording of the concluding round table was used as a qualitative source of synthesis. Since it did not introduce new quantitative slides, it was treated as an interpretative and programmatic closing contribution, without adding numerical data not documented in previous presentations or institutional sources.

The methodology of the student surveys, as described in the congress presentation, was based on a three-stage Probability Proportional to Size (PPS) sampling design and administration by Computer Assisted Web Interviewing (CAWI). The sample supports national representativeness of the student populations considered.

Table 1. Sample and main characteristics of the 2026 student surveys, according to the recording of the National Centre on Addiction and Doping presentation.

Population	Sample size	Gender distribution	Age / school-track distribution
11-13 years	5,270 students	Male 49.1%; female 48.6%; prefer not to answer 2.3%	11 years 28.0%; 12 years 35.1%; 13 years 37.0%
14-17 years	6,882 students	Male 46.2%; female 51.2%; prefer not to answer 2.6%	14 years 19.86%; 15 years 26.5%; 16 years 26.75%; 17 years 26.84%; lyceum 31.30%; technical 38.94%; vocational 23.37%; arts 6.39%

 

3. THE ADULT POPULATION: DECLINING CIGARETTE USE, PERSISTENT NICOTINE EXPOSURE

PASSI data presented in 2026 document a substantial reduction in exclusive use of conventional cigarettes in the adult population. Among people aged 18-69 years, the prevalence of exclusive conventional cigarette use declined from 30% in 2008 to 18% in 2025. However, when the overall use of nicotine-containing products is considered – including conventional cigarettes, electronic cigarettes and heated tobacco products – the decrease is much more limited, from 30% to 27% over the same period.

The gap between the decline in combustible cigarettes and the persistence of overall nicotine exposure is the most important interpretative point. It suggests that new products do not always act as pure substitutes for cigarettes. In many cases they may maintain, integrate or stabilise nicotine use.

4. EVOLUTION OF CONSUMPTION IN ADULTS AND PEOPLE AGED 65 AND OVER: THE CONTRIBUTION OF PASSI AND PASSI D’ARGENTO

PASSI and PASSI d’Argento confirm the central thesis: the profile of the Italian smoker is changing. The public-health question can no longer be limited to “who smokes cigarettes”; it must include those who use nicotine through different devices, those who combine several products, those exposed passively to aerosols and those who want to quit but do not find structured healthcare support.

In PASSI 2024-2025 data, about 73% of the adult population does not use tobacco- or nicotine-based products, 18% uses conventional cigarettes exclusively, 4% combines cigarettes with other devices, and 5% uses only devices other than conventional cigarettes. In other words, a non-negligible share of the adult population is already outside the classical model of combustible smoking only, using electronic cigarettes, disposable devices or heated tobacco products.

Attempts to quit also reveal important weaknesses. About one third of smokers report having tried to quit in the previous 12 months, but three out of four attempts fail and only 13% achieve the stated goal during the observation period. The most common cessation method remains the unaided attempt, whereas access to healthcare services, medicines or structured pathways appears marginal.

A critical issue concerns health-professional advice. In PASSI 2024-2025 data, 51% of smokers aged 18-69 report having received advice from a healthcare professional to stop smoking. The frequency increases among heavy smokers, but remains insufficient considering the burden of smoking as a preventable risk factor. Among people aged 65 and over, advice is reported by 62% of smokers, with higher frequencies among those with chronic diseases and, in particular, respiratory conditions.

Finally, passive exposure must be updated to take account of new devices. In workplaces, perceived compliance with smoking bans is high and slightly improving. Within the home, however, a new tolerance emerges towards the exclusive use of electronic devices, even in families with children. The category “only electronic devices” indicates that part of the population distinguishes the aerosol of new products from conventional smoke and may perceive it as less problematic.

5. STUDENT POPULATION: OVERALL PREVALENCE, GENDER AND PRODUCT HIERARCHY

The recording of the National Centre on Addiction and Doping presentation makes it possible to specify the data and correct some overly generic formulations in the initial notes. In the last 30 days, 5.9% of students aged 11-13 used tobacco- or nicotine-containing products, corresponding to an estimated 93,449 students, and 37.1% of students aged 14-17, corresponding to an estimated 851,393 students. The expressions “about 93,000” and “over 850,000” remain correct for communication purposes; in a scientific article, however, it is preferable to report the point estimates presented in the presentation.

Gender differences are evident in both age groups: among 11-13-year-olds, consumption involves 6.9% of girls and 4.8% of boys; among 14-17-year-olds, the gap is wider, with 44.2% of girls and 30.3% of boys. It is nevertheless necessary to avoid a simplified reading of “feminisation”. Among pre-adolescents, overall consumption decreases compared with 2022 and the 2026 overall decline is compatible with the reduction observed among boys; however, compared with 2025, heated tobacco and electronic cigarette use increase among girls. Among 14-17-year-olds, between 2025 and 2026 the increase concerns mainly girls for electronic cigarettes and heated tobacco, while conventional cigarette use decreases.

The hierarchy of products is central. Electronic cigarettes are the most used product in both age groups: 5.2% among 11-13-year-olds and 30.8% among 14-17-year-olds. Heated tobacco slightly exceeds conventional cigarettes: 2.5% vs 2.4% among 11-13-year-olds and 22.8% vs 22.3% among 14-17-year-olds. The expression “overtaking conventional cigarettes” is therefore correct only if specified: it is a slight, but epidemiologically relevant, excess in 30-day prevalence.

Table 2. Prevalence of consumption in the last 30 days by age group, gender and product, according to the presentation recording.

Indicator	11-13 years	14-17 years	Interpretative note
Consumption of at least one tobacco/nicotine product	5.9%; 93,449 estimated students	37.1%; 851,393 estimated students	Point estimate from the video; may be rounded to about 93,000 and over 850,000 for communication purposes
Males	4.8%; 39,179	30.3%; 358,390	Lower prevalence than females
Females	6.9%; 52,967	44.2%; 490,142	Higher prevalence in both age groups
Conventional cigarettes	2.4%; 37,971	22.3%; 511,805	Decreasing compared with 2025
Heated tobacco	2.5%; 39,202	22.8%; 523,218	Slightly exceeds conventional cigarettes
Electronic cigarettes	5.2%; 83,008	30.8%; 705,356	Most used product

 

Table 3. Variation 2025-2026 by product and gender: data to be used precisely to avoid improper interpretation of trends.

Age/product	Total 2025 -> 2026	Males 2025 -> 2026	Females 2025 -> 2026	Correct interpretation
11-13 / conventional cigarettes	3.2% -> 2.4%	3.4% -> 2.2%	2.8% -> 2.5%	Overall decrease, mainly among males
11-13 / heated tobacco	2.7% -> 2.5%	3.1% -> 1.8%	2.2% -> 3.2%	Overall stable/slightly decreasing; increase among females
11-13 / electronic cigarettes	6.3% -> 5.2%	6.1% -> 4.0%	6.1% -> 6.4%	Overall decrease; slight increase among females
14-17 / conventional cigarettes	24.5% -> 22.3%	21.4% -> 19.5%	27.2% -> 25.0%	Decrease in both genders
14-17 / heated tobacco	22.4% -> 22.8%	16.0% -> 16.2%	28.0% -> 29.4%	Overall stability; increase among females
14-17 / electronic cigarettes	29.9% -> 30.8%	27.2% -> 25.3%	32.2% -> 36.3%	Increase driven by girls

 

6. INTENSITY OF USE, NICOTINE CONTENT AND EARLY INITIATION

The analysis of intensity of use shows that prevalence must be integrated with frequency and amount of exposure. Among 11-13-year-old consumers, use for 20-30 days in the last month concerns 23.2% of conventional cigarette users, 17.4% of heated tobacco users and 22.6% of electronic cigarette users. Among 14-17-year-olds, the corresponding percentages rise to 34.0%, 37.8% and 31.8%. These data should not be automatically translated into clinical diagnoses of dependence, but they indicate frequent-use patterns compatible with a higher risk of nicotine dependence.

For electronic cigarettes, the recording clarifies an important point that needed correction in the initial notes: among 11-13-year-old e-cigarette users, 42.9% report using liquids with nicotine, 23.0% use both nicotine and nicotine-free liquids, and 15.2% do not know whether the product contains nicotine. Therefore, the proportion of users exposed to nicotine is at least 65.9%, not simply 42.9%. Among 14-17-year-olds, the proportion exposed to nicotine reaches 86.3%.

The amount of use reinforces this interpretation. Among e-cigarette users, 15.8% of 11-13-year-olds and 19.4% of 14-17-year-olds report more than 200 puffs per day. For heated tobacco, use of at least 11 sticks per day concerns 8.0% of 11-13-year-olds and 12.9% of 14-17-year-olds. For conventional cigarettes, consumption of at least 11 cigarettes per day concerns 2.1% of 11-13-year-olds and 7.8% of 14-17-year-olds.

Early initiation must be formulated precisely. It is not correct to write generically that “20% of 11-13-year-olds started before the age of 10”: the recording shows that, among 11-13-year-old consumers, about one fifth report first use at age 10 or earlier: 22.9% for conventional cigarettes, 20.9% for heated tobacco and 19.5% for electronic cigarettes. Mean ages at first use are 11.12 years for conventional cigarettes, 11.41 for heated tobacco and 11.38 for electronic cigarettes. Among 14-17-year-olds, the corresponding mean ages are 13.57, 14.10 and 13.58 years.

Table 4. Indicators of intensity of use and early initiation.

Indicator	11-13 years	14-17 years	Interpretation
Use 20-30 days/month: conventional cigarettes	23.2% of users	34.0% of users	Frequent use, not a clinical diagnosis
Use 20-30 days/month: heated tobacco	17.4% of users	37.8% of users	Frequent use, higher among 14-17-year-olds
Use 20-30 days/month: electronic cigarettes	22.6% of users	31.8% of users	Frequent use
E-cigarettes with nicotine exposure	65.9% of users; 15.2% do not know	86.3% of users; 6.4% do not know	Corrects the “42.9%” figure: that refers only to exclusive use with nicotine
More than 200 puffs/day	15.8% of e-cigarette users	19.4% of e-cigarette users	Indicator of high-intensity use
First use at age 10 or earlier	19.5%-22.9% depending on product	Not applicable as main threshold	Not “before age 10”, but “at age 10 or earlier”

 

7. POLY-USE: FROM ACCESSORY BEHAVIOUR TO DOMINANT PATTERN

Poly-use is one of the most relevant findings of the presentation. Among 11-13-year-old users, the proportion reporting combined use of two or more products increased from 26.0% in 2022 to 45.5% in 2025 and 51.4% in 2026. In the same group, exclusive use of single products decreases, while the combination of heated tobacco + electronic cigarettes and simultaneous use of all three main products increase in particular.

Among 14-17-year-olds, poly-use is even more consolidated: 38.7% in 2022, 62.4% in 2024, 70.7% in 2025 and 69.5% in 2026. The 2026 figure therefore indicates a slight decrease compared with 2025, but remains at very high levels. It is inaccurate to describe it simply as “constantly increasing” when the last year is considered; the correct formulation is that poly-use remains very high and has strongly consolidated compared with 2022.

Table 5. Exclusive use and poly-use among students who used products in the last 30 days.

Age/year	Only conventional	Only e-cig	Only HTP	Conventional + e-cig	HTP + e-cig	All three	Total poly-use
11-13 / 2022	12.8%	57.9%	3.3%	15.8%	3.6%	6.3%	26.0%
11-13 / 2025	7.0%	41.2%	6.2%	15.6%	9.7%	18.3%	45.5%
11-13 / 2026	4.8%	39.3%	4.5%	13.7%	15.4%	20.9%	51.4%
14-17 / 2022	26.9%	26.6%	7.8%	13.3%	3.3%	16.6%	38.7%
14-17 / 2024	13.3%	13.9%	10.4%	11.0%	9.3%	27.0%	62.4%
14-17 / 2025	6.2%	18.3%	4.7%	15.6%	11.4%	34.5%	70.7%
14-17 / 2026	5.6%	19.7%	5.1%	13.2%	15.1%	34.8%	69.5%

 

8. NICOTINE POUCHES: EMERGING SIGNAL AND EXTREME POLY-USE

Nicotine pouches represent an emerging signal, but they must be described by distinguishing experimentation, recent use and use modalities. Among students aged 14-17, 9.1% report having tried them at least once in their lifetime, compared with 8.2% in 2025 and 3.8% in 2024. Use in the last 30 days concerns 3.3% of students, corresponding to an estimated 75,309 individuals, with higher prevalence among boys (4.5%) than girls (2.1%).

The profile of users is strongly male: among students using pouches, 66.8% are male, 31.0% female and 2.1% prefer not to answer. Prevalence increases with age, from 2.5% at 14 years to 4.5% at 17 years. First-contact routes are heterogeneous: 26.6% personal purchase, 6.1% gift from parents or relatives, 27.7% gift at promotional events, 4.7% offer from friends and 35.1% offer from other people. These data indicate that the category “other people” must not be automatically interpreted as an online channel: it should be described as a grey area requiring further investigation.

Among pouch users, 51.9% report use for 1-2 days in the last month, but 13.3% used them for 20-30 days. The usual number is one pouch per day in 63.8% of cases, while 10.4% report five or more pouches per day. Weekend or holiday use is reported by 44.8%. The most commonly reported flavours are fresh/menthol (48.2%) and fruity (45.7%); 38.8% report not using flavoured pouches.

The most critical point is poly-use: only 5.5% of pouch users use them exclusively, while 94.5% combine pouches with one or more other products. In particular, 51.7% simultaneously use all four products considered: conventional cigarettes, heated tobacco, electronic cigarettes and nicotine pouches. In this subpopulation, pouches do not appear to be substitutes, but rather an additional source of nicotine exposure.

Table 6. Nicotine pouches among students aged 14-17: main indicators.

Indicator	2026 figure	Scientific interpretation
Lifetime experimentation	9.1%; 8.2% in 2025; 3.8% in 2024	Increasing phenomenon compared with 2024
Use in the last 30 days	3.3%; 75,309 estimated students	First year of specific monitoring of recent use
Gender distribution	Males 4.5%; females 2.1%; among users: 66.8% males	Unlike other products, male predominance
First contact	26.6% personal purchase; 27.7% promotional events; 35.1% other people	Channels requiring further investigation; do not infer “online” automatically
Use 20-30 days/month	13.3% of users	Frequent use in a relevant minority
Five or more pouches/day	10.4% of users	Potentially high nicotine exposure, especially if combined with other products
Poly-use	94.5%; all four products 51.7%	Signal of extreme multi-product exposure

 

9. EMERGING EVIDENCE ON HEALTH RISKS AND INTERVENTION PERSPECTIVES: THE CONTRIBUTION OF BOFFI’S PRESENTATION

The presentation by Roberto Boffi, pulmonologist, Head of the SSD Pneumology Unit at the Fondazione IRCCS Istituto Nazionale dei Tumori of Milan and President of the Italian Society of Tobaccology, integrates the epidemiological picture with a clinical and regulatory reading of new tobacco and nicotine-containing products. The starting point is that the market is no longer organised around a single product, but around a rapidly evolving ecosystem in which electronic devices, heated tobacco products, nicotine pouches, flavours, different nicotine concentrations and modes of use compatible with continuous consumption coexist [7].

According to the presentation, the new-product landscape is made complex by four elements: the continuous launch of devices, the ambiguous relationship with conventional smoking, poly-use and the effect of the regulatory framework. This perspective is especially relevant because it prevents a simplified interpretation of the phenomenon: reduced combustion does not automatically mean absence of risk, nor does adoption of a new product itself correspond to a therapeutic cessation pathway.

9.1 ELECTRONIC CIGARETTES: DEVICES, FLAVOURS, NICOTINE SALTS AND THE “ENDLESS EXPERIENCE”

Boffi reviewed the main models currently on the market: tank systems, pod-mod/pod systems and disposable devices. Their appeal derives from technical and commercial features that must be considered as determinants of consumption: a wide variety of flavours, different nicotine strengths, ease of use, possibility of use in many contexts and lower social visibility compared with conventional cigarettes. In particular, the availability of non-tobacco flavours is a central element of youth appeal. Studies by Leventhal cited in the presentation show that non-tobacco flavours increase product appeal and may be particularly relevant in groups that do not obtain direct health benefit from switching from combustible cigarettes to e-cigarettes, such as young non-smokers or users not oriented towards cessation [23].

A decisive technical element concerns nicotine formulation. Compared with free-base nicotine, nicotine salts produce a smoother throat hit, faster absorption and a more immediate but shorter effect; they are compatible with closed systems such as pod-mods and disposable devices and are closer to the experience of conventional smoking. This configuration facilitates repeated, discreet and potentially continuous use. The slide defined this pattern as an “endless experience”: the device can be used intermittently or almost continuously, without a clear unit limit, encouraging constant micro-doses of nicotine during the day and strengthening the behavioural component of dependence.

9.2 VAPING CESSATION: SUBSTANTIAL DEMAND FOR HELP, STILL IMMATURE EVIDENCE

A major contribution of the presentation concerned vaping cessation. Boffi emphasised that available studies on “quit vaping” often include exclusive e-cigarette users, young populations, short follow-up periods and a smoking history that is not always adequately considered. This should not be interpreted as absence of demand for care: in a study of US adolescents who were current e-cigarette users, 44.5% reported seriously thinking about quitting and 24.9% had attempted to stop completely in the previous year [24].

Among young adults, the study by Williams and colleagues in JAMA Network Open showed that 29.1% had quit or tried to quit electronic nicotine products in the previous 12 months. Social support from family and friends was the most commonly used method, while pharmacological treatment was very limited. In Boffi’s interpretation, this points to a gap between the need for cessation and the availability or use of structured clinical interventions [25].

On the evidence side, a Cochrane systematic review of interventions for vaping cessation indicates low-certainty evidence supporting text-message interventions in young people and young adults and low-certainty evidence also for varenicline. Evidence on combined nicotine replacement therapy, cytisine/cytisinicline and gradual reduction of vaping remains uncertain or inconclusive because of risk of bias and imprecision [26].

Some recent trials provide promising but not definitive signals. In a randomised study of 261 young people aged 16-25 years, varenicline plus counselling produced higher abstinence rates than placebo plus counselling and counselling alone at both 12 and 24 weeks [27]. In adults using e-cigarettes, the ORCA-V1 study showed that cytisinicline plus behavioural support increased abstinence compared with placebo at end of treatment and at 4-month follow-up [28]. These findings are relevant, but must be transferred with caution to the Italian adolescent population because of differences in age, regulatory context, available products and poly-use patterns.

9.3 CARDIOVASCULAR, BIOLOGICAL AND RESPIRATORY RISKS OF E-CIGARETTES: NON-INNOCUOUSNESS AND THE PROBLEM OF DUAL USE

The most important part for public-health discussion concerns risk signals associated with e-cigarettes. The presentation cited experimental and clinical evidence indicating that vaping cannot be considered harmless. Californian studies on endothelial function suggest that both combustible smoking and chronic e-cigarette use can impair endothelial function; in addition, inhalation of irritant aerosols may activate neurovascular mechanisms and contribute to vascular dysfunction. This is especially relevant in dual-use patterns, where the potentially harmful effects of conventional cigarettes and e-cigarettes may add up rather than replace each other [29].

Boffi also referred to biological and epigenetic evidence documenting DNA methylation changes in oral mucosal cells among e-cigarette users and smokers. These findings should not be presented as definitive proof of oncological causality, but as biological signals consistent with the need for caution in public communication about new products [30].

Particular caution is needed with the data on lung-cancer risk in combined use. The case-control study by Bittoni and colleagues, cited in the presentation, compared 4,975 lung-cancer cases with 27,294 controls and suggests that combined vaping and cigarette smoking is associated with higher risk than cigarette smoking alone. As an observational study, it does not permit definitive causal statements, but it reinforces a practical conclusion: dual use should not be communicated as a safe or automatically risk-reducing strategy [31].

9.4 HEATED TOBACCO: LESS COMBUSTION DOES NOT MEAN ABSENCE OF BIOLOGICAL HARM

For heated tobacco products, the presentation recalled preclinical and cellular evidence that should be integrated with adolescent epidemiological data. A 2026 study on bronchial cells showed that aerosol extract from heat-not-burn products, similarly to conventional cigarette extract, may increase post-translational protein modifications, influence cell viability and increase apoptotic mechanisms, with a possible role in biological pathways relevant to rheumatoid arthritis [32]. Again, this does not equate to proof of clinical outcomes in the general population, but it contradicts the idea that heated tobacco is biologically neutral.

9.5 NICOTINE POUCHES: SYSTEMIC EXPOSURE, DISCREET USE AND REGULATORY RISK

Nicotine pouches are the most critical emerging product from a regulatory perspective. They are non-combustible and do not contain tobacco in the conventional sense, but they release nicotine through buccal absorption. The pharmacokinetic review cited in the presentation shows that 4-mg pouches may provide total nicotine exposure similar to cigarettes, although with lower peak concentrations and longer absorption times. This profile matters because it may favour discreet, repeated and difficult-to-detect use, especially in school or social settings [33].

The concerns raised by Boffi are consistent with the WHO position, which in 2026 drew attention to aggressive marketing of nicotine pouches, high nicotine levels, youth-oriented flavours and digital promotional channels. Early nicotine use may increase the likelihood of long-term dependence and subsequent use of other nicotine- or tobacco-containing products [4,21]. In this article, this directly connects with Italian data on 14-17-year-olds: pouches do not appear to be a substitute product, but an additional nicotine source in often multi-product profiles.

9.6 INTERVENTION PERSPECTIVES: SMOKE-FREE/VAPE-FREE ENVIRONMENTS AND RESEARCH-INTERVENTION

The concluding part of the presentation shifted from evidence of risk to operational perspectives. Boffi presented the case of the Air Quality Regulation of the Municipality of Milan, in force from 1 January 2025, extending the smoking ban to all public or publicly used areas, except isolated places where a distance of at least 10 metres from other people is respected. The rationale is to reduce active smoking and exposure to second-hand smoke in public spaces, including the areas in front of hospitals.

Within the Istituto Nazionale dei Tumori of Milan, a research-intervention by the Smoking Cessation Centre of the Pneumology Unit was presented, based on a questionnaire among employees, pre-post observations of the number of smokers/vapers near the entrance and signage interventions. According to the slide, among 885 respondents, 56.3% reported smelling conventional or electronic smoke due to smokers in front of the entrance, 73.4% supported the outdoor smoking ban introduced by the Municipality of Milan and 68.8% supported creating a smoke-free area in front of the entrance. Observations in the area found an average of 38 smokers/vapers per hour, 62% within 10 metres and 38% beyond 10 metres. Product types observed included mainly conventional cigarettes, but also heated tobacco and e-cigarettes.

This example is important because it translates prevention into a measurable model: detect exposure, intervene in the setting, evaluate behaviour before and after the intervention. The lesson is twofold. First, smoke-free policies should evolve into smoke-free and vape-free policies, because aerosols from new products are now part of the exposure landscape. Second, prevention of new products requires environmental, regulatory and clinical interventions, not only individual educational messages.

Overall, Boffi’s contribution strengthens the central thesis of this article: the transition from cigarette to nicotine is not only a change of product, but a change in risk, dependence patterns, clinical evidence and intervention strategies. Public health must avoid both unsupported alarmism and minimisation of risk, adopting communication grounded in evidence, regulatory prudence and strengthened cessation pathways.

10. PAEDIATRIC EXPOSURE TO NEW TOBACCO- AND NICOTINE-BASED PRODUCTS: RESPIRATORY EVIDENCE AND THE ROLE OF THE PAEDIATRICIAN

The presentation on exposure to new tobacco- and nicotine-based products in paediatric age shifts the analysis from epidemiological data alone to the biological vulnerability of children and adolescents. The central point is that new products do not automatically reduce health risk: they change exposure routes, risk perception, modes of use and the ability of adults to control exposure.

A conceptual correction is essential: the aerosol of electronic cigarettes is not “water vapour”. The slides recalled the possible presence, depending on device and liquid, of nicotine, solvents, flavours, aldehydes, volatile organic compounds, metals and fine/ultrafine particulate matter. This composition makes it inappropriate to describe exposure as harmless or simply different from combustible smoke.

The paediatric relevance derives from three elements. First, the child and adolescent lung is still developing. Second, low risk perception facilitates both direct and passive exposure. Third, flavours, design and ease of use normalise consumption in family and school environments.

10.1 AEROSOL, AIRWAYS AND LUNG FUNCTION

From a respiratory perspective, the presentation described a plausible pathogenic chain: exposure to aerosol and particulate matter, oxidative stress, airway inflammation, impaired mucociliary clearance, bronchoconstriction and possible remodelling of the small airways. Clinically, this may translate into cough, wheezing, dyspnoea, chest tightness, exercise intolerance and functional changes compatible with obstructive involvement.

This framework is consistent with the SIMRI position statement on vaping and with the 2025 SIP-SIMRI joint position paper, which describe ENDS, heated tobacco and nicotine pouches as products rapidly spreading among adolescents, supported by flavours, marketing and distorted perceptions of lower risk.

10.2 LONG-TERM OUTCOMES AND VULNERABILITY OF THE DEVELOPING LUNG

The section on long-term outcomes recalls five risk areas: reduced lung function, increased risk of chronic respiratory disease, greater vulnerability to infections, effects on lung development and potential increase in cancer risk in the respiratory tract. In a scientific article these elements should be presented as risk signals and biological plausibility, not as definitive demonstration of individual causality.

Particularly relevant is passive and residual exposure. The presentation described the “invisible pathways of risk”: first-hand smoke, second-hand smoke, third-hand smoke and passive aerosol from electronic devices. Tolerance of domestic e-cigarette and heated tobacco use may expose children and adolescents to irritants and nicotine without the same social perception associated with conventional smoke.

10.3 NICOTINE POUCHES, SNUS AND PAEDIATRIC RISK

Nicotine pouches were described as single-dose products containing nicotine, flavours and other ingredients, placed between gum and lip to allow absorption through the oral mucosa. Their discreet use and lack of visible aerosol make them especially difficult for families and schools to monitor.

The comparison with snus is useful to avoid simplification. Snus is moist oral tobacco powder and is not sold in Italy, whereas nicotine pouches contain nicotine without tobacco. Both, however, raise issues of nicotine exposure, youth appeal and accidental ingestion in young children.

10.4 PAEDIATRIC PREVENTION: SCREENING, COUNSELLING AND THE RESPIRA NETWORK

The presentation assigned an operational role to the paediatrician. The RESPIRA network – Inter-Society Paediatric Network for Reducing Tobacco Smoking in Adolescence – was presented as a model for strengthening early detection, counselling and the connection between paediatrics, school, family and territorial services.

The proposed pathway includes early screening of use and family exposure, assessment tools such as mFTQ and HONC, brief counselling based on the 5As, parental involvement, education on new products and referral to specialist services when dependence, respiratory symptoms, intensive exposure or multi-product use emerge.

From a regulatory perspective, the presentation highlighted measures consistent with protecting minors: limiting the attractiveness of flavours, reducing device visibility, strengthening enforcement of the ban on sales to minors and promoting domestic, school and sports environments free from smoke, aerosol and nicotine.

Table 7. Respiratory risks and preventive implications of paediatric exposure to new nicotine-containing products.

Area	Evidence recalled in the presentation	Reading for the article
E-cigarette aerosol	Not simple water vapour; possible presence of nicotine, solvents, flavours, aldehydes, VOCs, metals and particulate matter	Avoid formulations suggesting harmlessness; describe exposure as chemically complex
Paediatric airways	Inflammation, oxidative stress, altered mucociliary clearance and bronchoconstriction	Specific relevance for the developing lung
Respiratory symptoms	Cough, wheezing, dyspnoea, chest tightness, exercise intolerance	Integrate respiratory history with nicotine use/exposure
Nicotine pouches	Discreet, flavoured products with oral absorption and risk of accidental ingestion	Monitor products without combustion and without aerosol as well
Prevention	Screening, counselling, RESPIRA network, family and school	Integrated paediatrician-services-school-family approach

 

11. TOXICOLOGICAL SURVEILLANCE OF ADVERSE EVENTS: PRELIMINARY RESULTS FROM THE MILAN POISON CONTROL CENTRE

The presentation on the observational analysis of the Milan Poison Control Centre introduces an additional level of interpretation: not only consumption prevalence or chronic respiratory risks, but also acute adverse events resulting from appropriate or inappropriate use of tobacco and/or nicotine-containing products. This contribution is particularly relevant because Poison Control Centres capture real accidental or intentional exposures, often not detected by population surveillance.

11.1 SCOPE OF THE ANALYSIS AND ROLE OF THE POISON CONTROL CENTRE

The Poison Control Centre (PCC) is presented as a mainly telephone-based medical service for the population and health professionals, providing toxicological consultation. In line with the 2008 State-Regions Agreement, PCC functions include management of poisoning cases, toxicological analysis, surveillance, vigilance and alert, scientific research, and training in prevention, diagnosis and treatment of poisoning.

The report concerns the observational analysis conducted by the Milan Poison Control Centre for the Italian National Institute of Health on adverse events arising from congruent or incongruent use of tobacco products and/or nicotine-containing products during the period 1 October 2025-30 September 2026; the data presented are from the interim report 1 October 2025-31 March 2026. The preliminary and observational nature of the data requires caution: they do not estimate population prevalence, but describe events brought to the PCC’s attention.

11.2 PRELIMINARY CASE SERIES AND EVENT PROFILE

The preliminary case series includes events reported mainly by private citizens (75 requests), followed by hospital physicians (26), an out-of-hospital physician (1) and a veterinarian (1). Sex distribution includes 54 males and 48 females; a puppy is reported separately and not included in the sex chart. This apparently marginal element expands the risk perimeter to companion animals, with clinical, emotional and economic implications for families.

Age distribution shows marked paediatric involvement: 18 cases in children aged 0-11 months, 39 cases in the 12-23-month group, 14 cases in the 2-4-year group, 3 cases in the 5-10-year group, 6 cases in the 11-15-year group and 1 case in the 16-18-year group. Adults are mainly present in the 19-30-year group (11 cases), while subsequent age groups are less represented. The strongest signal is therefore the weight of exposures in the first years of life, particularly through ingestion or accidental aspiration of products left unattended.

11.3 EXPOSURE ROUTES, SYMPTOMS AND TOXICOLOGICAL SEVERITY

The main exposure route is oral ingestion (68 events), followed by inhalation (25), oral-mucosal exposure (8), nasal mucosa (1) and ocular exposure (1). This distribution is consistent with the high paediatric presence: in small children, risk derives above all from product accessibility, oral exploration and the possibility of activating prefilled devices by simple inhalation.

Symptoms are reported in 49 events, whereas 54 are asymptomatic. The most frequent symptom categories are gastrointestinal (26), respiratory (11), neurological (8) and oropharyngeal (7); cardiac, ocular and metabolic symptoms are less frequent. This distribution is consistent with acute nicotine toxicity, which in mild-moderate forms may include nausea, vomiting, dizziness, tremor, sweating, tachycardia and hypertension; severe forms may progress to seizures, hypotension, hypotonia and paralysis.

Estimated risk classification shows a predominance of mild or moderate events: 10 events are indicated as none/non-toxic, 64 as mild, 27 as moderate, 1 as severe and 1 as not recorded. In the case epicrisis, 34 no intoxication cases, 18 mild intoxications, 8 moderate and 2 severe cases are reported. Although severe cases are few, their presence is sufficient to qualify these events as sentinel signals for public health.

11.4 PRODUCTS INVOLVED AND TECHNOLOGICAL CRITICALITIES

The agents most frequently involved are conventional cigarettes and loose tobacco (37 events), electronic cigarettes with nicotine-containing liquid refill (38), nicotine-free liquid refills (6), heated tobacco products with a metallic blade/foil (13), heated tobacco products without such component (6), and nicotine pouches (4). This distribution confirms that clinical toxicology must include the entire constellation of tobacco- or nicotine-containing products, not only combustible cigarettes.

The presentation highlighted three technical criticalities. The first is the presence of concentrated nicotine and other substances in refill liquids, prefilled devices and pouches. The second is the difficulty of knowing precisely the amount of nicotine in compressed tobacco products. The third is the presence of a metallic component in some heated tobacco sticks, which can transform paediatric ingestion into not only a toxicological problem but also a mechanical and gastroenterological one.

11.5 ACUTE NICOTINE TOXICITY AND ORAL PRODUCTS

Nicotine is rapidly absorbed through the main routes of exposure, is metabolised mainly in the liver, is eliminated in urine in limited unchanged amounts and has a variable half-life, shorter in smokers. Its action on nicotinic receptors of the central and peripheral cholinergic nervous system explains the combination of gastrointestinal, neurological, cardiovascular and neuromuscular symptoms observed in acute poisoning.

Nicotine pouches represent an emerging front. The presentation distinguishes snus, a tobacco-containing product not sold in Italy, from nicotine pouches. According to the report, pouches authorised in Italy may contain 4, 6, 10 or 16 mg of nicotine per pouch, within the indicated regulatory limit of 16.6 mg. Since one cigarette is estimated to deliver approximately 2 mg of absorbed nicotine, these products may generate high exposures, especially in individuals not accustomed to nicotine and in adolescent consumers.

11.6 SENTINEL CASES: ADOLESCENT DEPENDENCE, PAEDIATRIC INGESTION AND IMITATION OF ADULTS

The first sentinel case concerns a male adolescent under 16 years of age, with a history of ADHD, using about one pack per day of heated tobacco sticks for more than one year, with later introduction of the electronic cigarette. The family reported persistent nausea, vomiting episodes and aggressiveness, with repeated emergency department visits and exclusion of substance abuse.

Stopping the electronic cigarette was not accompanied by discontinuation of heated tobacco; the mere thought of being without cigarettes caused anxiety and concern. The case is relevant because it shows how heated tobacco can become part of trajectories of dependence and multi-product use in adolescence.

The second sentinel case concerns a 1-year-old girl, 10 kg, after ingestion of four heated tobacco sticks containing a metallic component. The child arrived at the emergency department after five episodes of vomiting at home, pallor, tachycardia, distress and sweating. Radiological examination located the metallic component in the stomach; attempted endoscopic removal failed, requiring intensive care admission, sedation and airway protection. After about 12 hours, tobacco fragments and the metallic component were evacuated. The case shows that HTPs introduce a composite risk: toxicological because of tobacco/nicotine and mechanical because of device components.

A third element concerns accidental aspiration of prefilled electronic devices by children imitating adults. Twenty-two cases aged 0-8 years were detected, most under three years of age. Prefilled devices can be activated by simple inhalation and may contain reservoirs up to 2 mL of liquid with a nicotine limit of 20 mg/mL. Even when observed symptoms are mild, the event is relevant because it signals domestic accessibility, behavioural imitation and the risk of early memorisation of the consumption gesture.

11.7 IMPLICATIONS FOR PREVENTION, CLINICAL PRACTICE AND SURVEILLANCE

The toxicological reading requires stronger domestic prevention: safe storage of liquids, prefilled devices, sticks and pouches; avoiding use in front of children; informing parents that electronic devices can be easily activated; and attention to mechanical risk from components such as metallic elements in sticks. Clinically, paediatricians, emergency physicians and territorial operators should include not only cigarettes and tobacco in the history, but also e-cigarettes, HTPs, liquid refills, disposable devices and nicotine pouches.

The main value of the presentation is methodological: collaboration between Poison Control Centres and public-health institutions makes it possible to detect emerging risks from market products quickly. PCC data do not replace epidemiological surveillance, but complement it, transforming isolated clinical events into early signals useful for regulation, prevention and professional training.

Table 8. Preliminary results of the Milan Poison Control Centre observational analysis and implications for the article.

Area	Data or evidence from the video	Scientific interpretation
Period	Analysis 01/10/2025-30/09/2026; interim data 01/10/2025-31/03/2026	Preliminary results, not a population prevalence estimate
Requesters	75 private citizens, 26 hospital physicians, 1 out-of-hospital physician, 1 veterinarian	The phenomenon involves homes, hospitals and even companion animals
Age	Strong paediatric involvement: 18 cases 0-11 months, 39 cases 12-23 months, 14 cases 2-4 years	The main risk concerns early childhood and the home environment
Exposure routes	Oral ingestion 68; inhalation 25; oral-mucosal 8; nasal 1; ocular 1	Product accessibility and imitation of adults are central determinants
Symptoms	49 symptomatic events; mainly gastrointestinal, respiratory, neurological and oropharyngeal	Consistent with acute nicotine toxicity and local irritation
Estimated risk	64 mild, 27 moderate, 1 severe; 10 none/non-toxic; 1 not recorded	Most cases are mild-moderate, but severe cases are sentinel events
Products involved	Cigarettes/tobacco, nicotine refills, HTPs with/without metallic component, pouches	Prevention must cover all products, not only combustible cigarettes
Sentinel cases	Adolescent dependence on HTP/e-cig; paediatric ingestion of stick with metallic component; aspiration of prefilled devices	Clinical surveillance, counselling and domestic safety are needed

 

12. CESSATION OF TOBACCO AND NICOTINE USE: DATA, TRENDS AND IMPLICATIONS FOR THE ITALIAN SYSTEM

Silvano Gallus’s presentation placed cessation of tobacco and nicotine use within a clinical, epidemiological and policy perspective. The starting point is clear: tobacco smoking remains one of the main avoidable risk factors globally and causes a relevant loss of life expectancy. Historical data on British doctors’ cohorts, recalled in the presentation, show that smokers die on average about ten years earlier than non-smokers; more recent evidence suggests that the loss of life expectancy may be even greater.

Cessation, however, produces substantial benefits even when it occurs in later adulthood: quitting at 60, 50, 40 or 30 years makes it possible to recover respectively about 3, 6, 9 and up to 10 years of life expectancy. This confirms that cessation should not be seen as a late or residual intervention, but as a therapeutic and preventive measure with high impact.

12.1 BENEFITS OF CESSATION AND TREATMENT OF DEPENDENCE

Cessation of tobacco and nicotine use should be considered treatment of dependence, not a simple act of individual willpower. The 2023 Italian guidelines and recent international recommendations indicate that counselling, behavioural support and pharmacotherapy increase the probability of success. Pharmacological options include nicotine replacement therapy, varenicline, bupropion, nortriptyline and cytisine/cytisinicline, to be used within a structured and monitored clinical pathway. The novelty in 2025-2026 is the strengthened role of cytisine: WHO has recognised its usefulness in treating tobacco dependence and, in Italy, reimbursement of a cytisine-based medicine has opened a concrete possibility for public access, provided it is connected with Smoking Cessation Centres and counselling.

12.2 FROM UNAIDED QUITTING TO STRUCTURED PATHWAYS IN SMOKING CESSATION CENTRES

A central message concerns the limitations of unaided attempts. Quitting alone is the most common approach, but also the least effective in the long term: only a limited proportion of smokers maintain abstinence without support. A structured pathway in a Smoking Cessation Centre, generally organised over 4-10 specialist sessions, includes clinical assessment, estimation of dependence level, assessment of motivation for change, pharmacological and psychological intervention either individually or in groups, and scheduled follow-up at 3, 6 and 12 months. This model makes explicit that cessation requires continuity of care and cannot be reduced to a single occasional piece of advice.

12.3 CYTISINE, REIMBURSEMENT AND ACCESS CRITICALITIES

The presentation attached importance to cytisine, which is now particularly relevant for two reasons: first, it has entered the international debate on essential medicines for cessation; second, in Italy, reimbursement may reduce an economic barrier that for years limited access to treatment. The organisational point remains decisive: availability of the medicine works only if the patient enters a clear pathway, with clinical assessment, counselling, monitoring and stable linkage with Smoking Cessation Centres. Otherwise, the risk is to focus on the drug and lose the sense of the comprehensive treatment of dependence.

12.4 ELECTRONIC CIGARETTES AND CESSATION: DISTINCTION BETWEEN CLINICAL TRIALS AND REAL-WORLD USE

The presentation proposed a rigorous interpretation of the role of electronic cigarettes in cessation. In real-world settings, electronic cigarettes cannot be considered a generalisable solution: they may favour dual use, maintenance of nicotine dependence and transition from one product to another without real cessation.

Clinical reviews, including the Cochrane review mentioned in the presentation, indicate that nicotine-containing e-cigarettes may increase cessation rates for conventional cigarettes compared with some comparators. However, this result derives from controlled settings, does not automatically translate into a population benefit and does not resolve problems related to prolonged use, dual use, vaping dependence and attractiveness to non-smokers. The most rigorous formulation is therefore: e-cigarettes may have a role in some controlled clinical pathways for adult smokers, but they are not a risk-free public-health strategy and are not an appropriate solution for young people.

12.5 TOBACCO CONTROL SCALE 2025 AND SYSTEM CAPACITY TO SUPPORT CESSATION

The presentation referred to the Tobacco Control Scale 2025, which quantifies the degree of adoption of tobacco-control policies across European countries. Dimensions include product price, smoke-free public places, spending on public information, advertising bans, health warnings on packages and access to cessation treatment. For the dimension “cessation treatments”, Italy obtains 5 points out of 10: the score indicates an intermediate condition, with some tools available but substantial room for improvement, especially regarding systematic recording of smoking status, brief advice in primary care, reimbursement of treatments and territorial coverage of specialist services.

12.6 ATTEMPTS TO QUIT IN EUROPE AND ITALY

Eurobarometer 2020 data presented in the talk indicate that, in Europe, the propensity to try to quit varies widely across countries. Italy appears among the countries with a high proportion of smokers who have tried to quit at least once, but with a limited proportion of recent attempts. In the discussed representation, about 67% of Italian smokers report having tried to quit more than one year earlier and about 4% in the last 12 months.

This figure should be read with methodological caution, but it suggests an important point: cessation is often a recurrent intention, not always accompanied by timely support. PASSI data add a national surveillance perspective: about one third of adult smokers try to quit each year, but most attempts fail. The gap between desire to quit and successful cessation is therefore one of the main challenges for the National Health Service.

12.7 NEW PRODUCTS AND DEMAND FOR CESSATION

The presentation also extended the cessation issue to new products. Users of electronic cigarettes and heated tobacco products may also express a desire to quit, but services and counselling are still largely organised around conventional cigarettes. This creates a mismatch between the changing nicotine market and available cessation pathways. Smoking Cessation Centres should therefore assess all nicotine products, including dual use and poly-use, and adapt counselling and pharmacological support accordingly.

12.8 INTERPRETATIVE SYNTHESIS

Gallus’s contribution strengthens the idea that cessation should become a structural component of tobacco control. It is not enough to measure prevalence or regulate products; the system must also make quitting possible, accessible and continuous. The future of cessation in Italy depends on an integrated model linking brief advice, primary care, specialist services, reimbursed pharmacotherapy, digital tools, follow-up and systematic outcome evaluation.

13. TERRITORIAL SERVICES FOR THE TREATMENT OF TOBACCO AND NICOTINE DEPENDENCE: RESULTS OF THE 2026 ISS CENSUS

The presentation on the ISS census of territorial services for the treatment of tobacco and nicotine dependence provides an organisational reading of the Italian response. The key point is that the network of Smoking Cessation Centres represents a strategic resource, but it remains heterogeneous in distribution, access criteria, professional composition, use of pharmacological treatments, outcome monitoring and data recording.

13.1 NATIONAL NETWORK, TERRITORIAL DISTRIBUTION AND DENOMINATORS

The census refers to 209 active centres for the main organisational variables, while a regional distribution slide uses the denominator of 221 centres. The two denominators should not be confused or summed. The territorial distribution indicates greater concentration in the North (117 centres, 53%), followed by the South and Islands (56 centres, 25%) and the Centre (48 centres, 22%). The correct interpretation is that Italy has a national network, but with uneven territorial density.

13.2 ECONOMIC AND PROCEDURAL ACCESSIBILITY

Access remains variable. In the centres surveyed, 52% report free access, 38% require a co-payment, 7% a voluntary contribution, 5% a mandatory contribution and 5% a membership fee. Procedural access is also uneven: 74% of centres allow access without a medical prescription, 30% require a general practitioner referral and 8% indicate other arrangements. This heterogeneity may become a barrier, especially for people with lower socioeconomic resources or lower health literacy.

13.3 REFERRAL, INTAKE AND WAITING TIMES

Referral routes are varied: voluntary access is reported by 81% of centres, specialist referrals by 69%, general practitioner referrals by 67%, family or friends by 59%, the Quitline by 33% and pharmacies by 11%. The number of users taken into care in responding centres is 13,510 (n=166), a figure to be interpreted as an activity measure rather than a population prevalence estimate. Waiting times for first visit are under 7 days in 9% of centres, 7-15 days in 47%, 16-30 days in 29% and over 30 days in 15% (n=196). About half of the centres can therefore receive users within 15 days, but a relevant share requires longer waiting times.

13.4 PSYCHOLOGICAL AND MEDICAL ASSESSMENT

The assessment phase generally includes collection of smoking history, evaluation of dependence, motivation, previous quit attempts and psychological or medical comorbidities. A robust intake should now include all nicotine products: conventional cigarettes, electronic cigarettes, heated tobacco, nicotine pouches, disposable devices and patterns of dual or poly-use. This is necessary because the new nicotine market makes the simple question “Do you smoke?” insufficient.

13.5 CARE OFFER AND PHARMACOLOGICAL TREATMENT

Counselling is widely present, often together with pharmacological treatment. The availability of cytisine introduces an important opportunity, but also requires clear prescribing, reimbursement and monitoring procedures. Pharmacological treatment should not be isolated from behavioural support: the evidence indicates that combined approaches produce better results than advice or medication alone.

13.6 EFFECTIVENESS ASSESSMENT, QUALITY AND INFORMATION SYSTEMS

A decisive weakness concerns outcome monitoring and data recording. Without shared indicators, it is difficult to compare activities, document effectiveness, identify unmet needs and justify reinforcement of the network. The census therefore should not be read only as a mapping exercise, but as a tool for quality improvement and accountability.

13.7 MULTIDISCIPLINARY TEAMS AND ORGANISATIONAL IMPLICATIONS

The treatment of tobacco and nicotine dependence requires multidisciplinary teams: physicians, psychologists, nurses, prevention technicians and other professionals. New products, dual use, adolescent use and co-occurring mental distress make it even more necessary to integrate addiction medicine, respiratory medicine, cardiology, oncology, paediatrics and community prevention.

Table 9. Territorial services for tobacco and nicotine dependence: key findings of the ISS census.

Dimension	Data reported in the slides	Interpretation for the article
Territorial network	209 centres for main organisational variables; 221 in the regional distribution slide	Use distinct denominators; avoid summing non-homogeneous indicators
Regional distribution	North 117 (53%); Centre 48 (22%); South/Islands 56 (25%)	National network with greater concentration in the North
Economic accessibility	Free 52%; co-payment 38%; voluntary contribution 7%; mandatory contribution 5%; membership fee 5%	Differentiated access models persist; possible economic barrier in some contexts
Access to first visit	Without prescription 74%; GP referral 30%; other 8%	Predominantly direct, but not uniform, access
Referral routes	Voluntary access 81%; specialists 69%; GP 67%; family/friends 59%; Quitline 33%; pharmacies 11%	Integrated intake between individual motivation, general medicine, specialist care and social network
Intake	13,510 users in responding centres (n=166)	Activity data, not epidemiological prevalence
Waiting time for first visit	<7 days 9%; 7-15 days 47%; 16-30 days 29%; >30 days 15% (n=196)	About half of centres within 15 days; relevant share beyond two weeks

 

14. SMOKING CESSATION CENTRES AND REGIONAL CONTEXTS: INSTITUTIONAL AND OPERATIONAL ARRANGEMENTS AND DEVELOPMENT PERSPECTIVES

The presentation on Smoking Cessation Centres and regional contexts complements the ISS census by placing the network within institutional arrangements, regional planning and development perspectives. It clarifies that a list of centres is not enough: services must be embedded in explicit governance, coordinated pathways, training, monitoring and connection with broader tobacco-control policies.

14.1 INTERINSTITUTIONAL GOVERNANCE AND INFORMATION SOURCES

Governance involves the Italian National Institute of Health, the Ministry of Health, the Department for Anti-Drug Policies, scientific societies, Regions and technical working groups. Information sources include national mapping of Smoking Cessation Centres, regional plans, prevention programmes, three-year plans and local organisational documents. These sources are essential to understand not only where centres are located, but how they work and how they are connected to regional systems.

14.2 INSTITUTIONAL AND ORGANISATIONAL ARRANGEMENTS OF SMOKING CESSATION CENTRES

Regional arrangements are heterogeneous. Centres may be located within addiction services, prevention departments, hospital units, pulmonology, cardiology, oncology, LILT or Third Sector organisations. This heterogeneity may be a strength when it allows proximity and flexibility, but it becomes a weakness when access, treatment offer and outcome evaluation are not standardised.

14.3 CLINICAL OPERATION AND CONTINUITY OF CARE

Operational continuity requires explicit pathways from first contact to follow-up. Access may be direct or by appointment; some contexts experiment with desks, mobile units or community-based activities. The crucial issue is that users should not be left to navigate fragmented services. A person who wants to quit should be able to identify quickly where to go, what treatment is available, who will follow them and how outcomes will be assessed.

14.4 REGIONAL HETEROGENEITY: POLICIES, TOOLS AND PILOT EXPERIENCES

Regional heterogeneity concerns policies, operational tools and pilot experiences. Examples include apps to support treatment with cytisine, digital monitoring tools, attention to e-cigarettes and emerging needs, and in some cases innovative approaches such as rTMS. These experiences are useful if they are evaluated and connected with shared standards rather than remaining isolated local initiatives.

14.5 DEVELOPMENT PERSPECTIVES AND CONNECTION WITH TOBACCO CONTROL

Development perspectives include stronger communication campaigns, evidence-based prevention, homogeneous access criteria, wider use of reimbursed treatments, professional training, regional coordination, digital support tools, attention to vaping cessation, shared guidelines and organisational review. The link with the Tobacco Control Scale is important: cessation services are one dimension of a broader policy system that also includes prices, advertising bans, smoke-free environments, warnings and enforcement.

Table 10. Regional contexts: institutional, operational and development implications.

Dimension	Examples reported in the presentation	Implication for public health
Institutional arrangement	Addiction services, prevention departments, hospitals, pulmonology/cardiology, LILT and Third Sector	Cessation requires integration between addiction services, prevention, specialist care and community actors
Planning	Regional Health Plans, Regional Prevention Plans, PP4, three-year plans	Tobacco control must enter routine planning rather than remain episodic
Access and network	Direct access in about one third of cases; appointment pathways; desks and mobile units	Need for more homogeneous access criteria and capacity to reach vulnerable users
Innovation	Apps during cytisine treatment, digital tools, monitoring, rTMS, attention to e-cigarettes and emerging needs	The network must update to new products, poly-use and vaping cessation
Regional governance	Technical tables, regional observatories, coordination of Smoking Cessation Centres, staff training	Standards, training and shared data are prerequisites for measuring quality and outcomes

 

15. THE ROLE OF LILT IN SUPPORTING CESSATION OF TOBACCO AND NICOTINE USE

The LILT presentation adds a historical and community dimension to the system response. LILT’s role should not be read only as a supplementary activity, but as part of the Italian tradition of prevention, counselling and group-based support for smoking cessation.

15.1 HISTORICAL ORIGIN AND METHODOLOGICAL CONTRIBUTION OF LILT

LILT has long contributed to tobacco prevention and dishabituation, including early institutional programmes and the development of group methods for quitting. The historical value of this contribution lies in combining health education, psychological support and territorial proximity, with attention to motivation, relapse prevention and the social context of smoking.

15.2 FROM THE NATIONAL TRAINING PLAN TO SMOKING CESSATION CENTRES

The presentation recalled training initiatives, including programmes to train group leaders and the 2004-2006 National Training Plan. These experiences helped to build professional capacity and to connect LILT activities with Smoking Cessation Centres and local healthcare services.

15.3 LILT TODAY: TRAINING, TERRITORIAL NETWORK AND COGNITIVE-BEHAVIOURAL MODEL

Today, LILT can contribute through training, territorial networks and cognitive-behavioural approaches. Group cessation programmes, the “Guadagnare Salute con la LILT” training platform and collaborations with ASL Smoking Cessation Centres, general practitioners, Community Houses, pharmacies and universities can make cessation more accessible and less medicalised without losing clinical rigour.

15.4 DEVELOPMENT PERSPECTIVES: YOUNG PEOPLE, NEW NICOTINE DEPENDENCE AND ENFORCEMENT AGAINST SALES TO MINORS

The new scenario requires LILT to address not only conventional cigarette smoking but also electronic cigarettes, heated tobacco, nicotine pouches and poly-use. Prevention aimed at young people must deal with flavours, social normalisation, marketing and access to products. Enforcement against sales to minors is a key component, but it must be accompanied by education, family involvement and accessible counselling.

15.5 SOS LILT: ORIENTATION, COUNSELLING AND ACCESS TO SERVICES

SOS LILT (800 998877) functions as a national channel for orientation, counselling and access to services. Its value lies in lowering the threshold for contact, offering confidential support and directing citizens towards appropriate pathways. In a system where many smokers still try to quit alone, telephone counselling and orientation can become an important bridge to structured treatment.

15.6 INTERPRETATIVE SYNTHESIS

LILT represents a historical and operational resource for the Italian response to tobacco and nicotine dependence. Its contribution is particularly relevant when connected with the public network of Smoking Cessation Centres, primary care, schools, pharmacies and community settings. In the new nicotine landscape, territorial proximity and structured methods may help transform intention to quit into effective treatment access.

16. ACCESSIBILITY, DOMESTIC AND SCHOOL ENVIRONMENTS

Accessibility to nicotine products remains a major critical issue. Despite the ban on sales to minors, students report direct purchase through tobacconists/bars and other channels. The proportion of sellers who do not refuse sales because of age, and the presence of products in promotional events or through unspecified “other people”, indicate weaknesses in enforcement and the need for stronger controls.

The school environment is central because it is both a place of prevention and a place where use may become visible and normalised. Reports of students seeing peers using nicotine products inside school premises, and in some cases observing adult staff using such products, indicate the need for clear school policies, surveillance of “blind spots” such as bathrooms and courtyards, and coherent behaviour by adult role models.

The home environment must also be considered. New products are often perceived as less disturbing than conventional cigarettes and therefore more tolerated indoors. This may increase passive exposure of children and adolescents to aerosols and residues, especially when families underestimate the chemical complexity of these emissions.

17. PSYCHOPHYSICAL HEALTH AND ASSOCIATED BEHAVIOURS

The student surveys show associations between nicotine use and other risk behaviours or indicators of psychological distress. Among 11-13-year-olds, alcohol use in the last month is reported by 48.4% of consumers versus 9.2% of non-consumers; among 14-17-year-olds, 78.3% of consumers versus 28.1% of non-consumers report alcohol use. Drunkenness is also more frequent among consumers.

Screening indicators for generalised anxiety and depression are higher among consumers, while adequate psychological well-being is lower. These data should not be interpreted as proof that nicotine causes anxiety or depression. They indicate an epidemiological association that may reflect vulnerability, shared risk factors, coping behaviours, social context and bidirectional relationships. From an intervention perspective, the implication is clear: prevention of nicotine use should be integrated with attention to adolescent mental health and other risk behaviours.

Table 11. Nicotine use, alcohol, drunkenness and indicators of psychological well-being in students.

Indicator	11-13-year-old consumers vs non-consumers	14-17-year-old consumers vs non-consumers	Note
Alcohol use in the last month	48.4% vs 9.2%	78.3% vs 28.1%	Behavioural association
Drunkenness in the last month	44.2% vs 5.9%	More frequent among consumers	Report without causal inference
Generalised anxiety	50.5% vs 21.7%	43.0% vs 26.7%	Screening scores
Depression	47.7% vs 21.5%	38.3% vs 26.1%	Screening scores
Adequate psychological well-being	53.8% vs 72.6%	50.5% vs 63.4%	Lower among consumers

 

18. PUBLIC-HEALTH RESPONSES: QUITLINE, SOS LILT, SMOKING CESSATION CENTRES AND PREVENTION

The Italian response includes multiple tools: the ISS Quitline, SOS LILT, Smoking Cessation Centres, regional services, school prevention, paediatric screening and regulatory enforcement. The strength of this architecture lies in its plurality; the weakness lies in the risk of fragmentation. A person who uses nicotine, whether through cigarettes, e-cigarettes, heated tobacco or pouches, should find a recognisable pathway rather than a dispersed set of services.

The Quitline and SOS LILT can provide orientation and first-level counselling. Smoking Cessation Centres can offer specialist evaluation, pharmacotherapy, behavioural support and follow-up. Schools and paediatricians can intercept early use. Regions can organise services and set standards. The challenge is to connect these levels in a measurable network, with shared indicators and communication strategies adapted to new products.

19. DISCUSSION

The overall interpretation of the conference data is clear: Italy is not simply experiencing a decline in smoking, but a reconfiguration of nicotine consumption. Conventional cigarette use is declining, but nicotine exposure persists through electronic cigarettes, heated tobacco, nicotine pouches and poly-use. This is particularly evident among adolescents and young adults, but also emerges in adult surveillance data.

The student data are especially relevant. They show early initiation, high prevalence among 14-17-year-olds, higher prevalence among girls, the dominance of e-cigarettes and the consolidation of poly-use. The most important interpretative correction is that not all trends are linear: some products decrease overall while increasing among girls; poly-use among 14-17-year-olds slightly decreases from 2025 to 2026 but remains extremely high. Scientific communication must therefore be precise and avoid both overstatement and minimisation.

Clinical and toxicological contributions complete the epidemiological picture. The new products cannot be described as harmless: aerosols contain complex mixtures, heated tobacco may have biological effects, nicotine pouches deliver systemic nicotine exposure, and Poison Control Centre data show acute events, especially in young children. At the same time, evidence should be presented with methodological prudence, distinguishing experimental, observational, clinical and surveillance data.

The challenge for the National Health Service is to move from prevention centred almost exclusively on combustible smoking to prevention centred on overall nicotine initiation and assisted cessation. This means intervening earlier, better and more continuously: countering product normalisation, strengthening brief counselling by health professionals, protecting homes and schools from smoke and aerosol, making structured cessation pathways more accessible and monitoring outcomes.

The integration of the LILT contribution further strengthens the territorial and community dimension of the response: cessation does not depend only on medicines or specialist services, but also on the ability to train operators, activate groups, orient citizens, intercept young people and connect voluntary-sector networks with the National Health Service.

The concluding round table confirms this reading: the value of the Conference is not only descriptive, but programmatic. The evidence presented requires a coordinated response integrating prevention, regulation, treatment and territorial governance, preventing the decline in conventional cigarettes from masking the stabilisation or reconfiguration of nicotine dependence.

20. LIMITATIONS OF THE ANALYSIS

This work is based on congress materials, institutional communications and authoritative scientific sources. Some data derive from official recordings of presentations and may not yet be available as full peer-reviewed publications. For this reason, congress data have been reported with methodological caution, avoiding causal statements where the evidence is observational or preliminary.

Student data are based on self-reported questionnaires, which may be affected by recall bias, social desirability bias or incomplete awareness of product content, particularly nicotine content in electronic cigarette liquids. Poison Control Centre data do not estimate population prevalence; they are sentinel clinical signals from cases brought to the centre’s attention. Data on new products are evolving rapidly and may change with market, regulatory and behavioural dynamics.

21. CONCLUSIONS

The data presented at the XXVIII National Conference “Tobacco Smoking and the National Health Service” indicate a clear transition in the Italian scenario: from smoking as a phenomenon centred on combustible cigarettes to nicotine exposure as a multi-product, age-sensitive and clinically complex phenomenon. The decline in conventional cigarettes remains an important public-health achievement, but it is no longer sufficient as the sole indicator of progress.

Electronic cigarettes, heated tobacco products and nicotine pouches have introduced new forms of initiation, maintenance and normalisation of nicotine use. Among students, the high prevalence of use in the 14-17-year age group, the early presence of consumption among 11-13-year-olds, the central role of girls in several trends and the consolidation of poly-use require a renewed preventive approach.

Public health should therefore adopt an integrated strategy: prevent nicotine initiation, protect minors, regulate product appeal, strengthen enforcement, address domestic and school exposure, expand cessation services, support pharmacological and behavioural treatment, monitor outcomes and coordinate regional and community resources. The final objective remains to reduce morbidity and mortality associated with tobacco use and the dependence that sustains it.

22. CONCLUDING ROUND TABLE OF THE XXVIII CONFERENCE: TECHNICAL SYNTHESIS AND OPERATIONAL PERSPECTIVES

The concluding round table of the XXVIII National Conference “Tobacco Smoking and the National Health Service” should be read as a moment of recomposition of the epidemiological, clinical, toxicological, organisational and regulatory contributions presented during the day. Its value does not lie in the introduction of additional numerical data, but in the construction of a common interpretative framework: tobacco smoking can no longer be addressed as a phenomenon limited to combustible cigarettes, but as a dynamic set of nicotine exposures, products, consumption practices, developmental vulnerabilities and response arrangements within the National Health Service.

22.1 FROM SMOKING TO NICOTINE DEPENDENCE: THE PARADIGM SHIFT

The first technical message emerging from the concluding discussion is the transition from a paradigm centred on “smoking” to one centred on “nicotine dependence”. The reduction in exclusive conventional cigarette use, while an important achievement of tobacco-control policies, is no longer sufficient to measure overall risk. Electronic cigarettes, heated tobacco products and nicotine pouches have changed access, maintenance and normalisation of dependence, especially among adolescents and young adults.

This perspective makes it possible to read PASSI and PASSI d’Argento data, student surveys, paediatric respiratory evidence, toxicological signals from the Poison Control Centre and organisational criticalities of Smoking Cessation Centres within one framework. The public-health issue is no longer only tobacco combustion, but cumulative, repeated and often multi-product exposure to nicotine, with effects on dependence, associated behaviours, respiratory health and demand for treatment.

22.2 YOUNG PEOPLE, GIRLS AND NEW PRODUCTS: PREVENTION BEFORE INITIATION

The concluding discussion reinforces the centrality of the youth population. The data presented during the Conference show that initiation occurs early, already in the 11-13-year age group, and that among 14-17-year-olds the consumption of tobacco- or nicotine-containing products reaches high levels. The critical element is not only prevalence, but the qualitative transformation of consumption: electronic cigarettes are the most used product among students, heated tobacco slightly exceeds conventional cigarettes and poly-use becomes recurrent.

Gender differences, with higher overall prevalence among girls for many products, require updated prevention. Prevention cannot be limited to generic messages on the dangers of smoking; it must address the mechanisms of appeal of new devices: flavours, technological design, discreet use, perception of lower risk, direct or indirect marketing, normalisation among peers and use in settings where conventional cigarettes would be more easily recognised.

Within this framework, the goal is not only to “make people smoke less” after dependence has stabilised, but to delay or prevent initiation. Prevention should start early, include primary and lower secondary school, involve families and paediatricians, and communicate clearly that non-combustible products are not harmless or neutral alternatives to cigarettes.

22.3 BIOLOGICAL, CLINICAL AND TOXICOLOGICAL RISK: APPLYING THE PRECAUTIONARY PRINCIPLE

A second axis of the round table concerns risk assessment. The conference presentations showed that new products must be analysed without simplification: less combustion does not mean absence of harm; aerosol does not mean water vapour; absence of visible smoke does not mean absence of exposure. Emerging evidence on e-cigarettes, heated tobacco, nicotine pouches and passive aerosol indicates biological, cardiovascular, respiratory and toxicological risk signals that require prudence, especially among minors and people with respiratory vulnerability.

The toxicological surveillance of the Milan Poison Control Centre adds an essential clinical perspective: new products do not generate only chronic or theoretical risks, but also acute events, especially in paediatric domestic settings, through accidental ingestion, aspiration, mucosal exposure or inappropriate use. Nicotine pouches and e-cigarette liquids raise specific concerns because they may concentrate high nicotine doses in packaging or forms of use perceived as less dangerous, more discreet and more easily accessible.

The technical conclusion is that, in the presence of evolving but coherent risk signals, public health should apply the precautionary principle. This means avoiding social normalisation of new products, not accrediting them as harmless, rigorously distinguishing controlled clinical studies from real-world use, and maintaining a regulatory position oriented to protection of minors and non-users.

22.4 CESSATION AND CARE PATHWAYS: FROM OCCASIONAL ADVICE TO AN INTEGRATED NETWORK

The round table also highlighted the need to strengthen cessation. Treatment of tobacco and nicotine dependence cannot be reduced to individual recommendation or personal will. Evidence from the presentations on cessation and territorial services shows that the most effective pathways integrate clinical assessment, counselling, psychological-behavioural support, evidence-based medications, follow-up and real access to Smoking Cessation Centres.

The critical issue is continuity of care. A person who smokes or uses nicotine products may encounter the system through many access points: general practitioner, paediatrician, specialist, pharmacy, school, ISS Quitline, SOS LILT, Smoking Cessation Centres, addiction services, pulmonology, cardiology, oncology, Community Houses and Third Sector organisations. The challenge is not to multiply isolated channels, but to build a recognisable, coordinated and measurable network capable of quickly guiding users to appropriate treatment.

The role of healthcare professionals is decisive. Advice to quit should become more frequent, systematic and documented, including not only conventional cigarette smokers but also dual users, heated tobacco users, e-cigarette users and users of other nicotine-containing products. New nicotine dependence requires new history-taking questions: not only “Do you smoke?”, but “Do you use nicotine-containing products?”, “Which products?”, “How often?”, “In which combinations?” and “Have you ever tried to quit?”.

22.5 SERVICES, REGIONS AND THIRD SECTOR: GOVERNANCE OF THE RESPONSE

The conclusions converge on an organisational point: the response to tobacco smoking and nicotine dependence requires multilevel governance. The ISS census of Smoking Cessation Centres, the review of regional arrangements and the LILT contribution show that Italy has a significant network of resources, but one that is heterogeneous in territorial distribution, accessibility, organisational models, team composition, free provision, pharmacological management and outcome monitoring systems.

Regional governance is the level at which evidence becomes practice. Regional Prevention Plans, Predefined Programme 4, three-year planning, prevention departments, addiction services, pulmonology, cardiology, oncology services, LILT and other territorial actors should be integrated in explicit pathways. The network of Smoking Cessation Centres must be visible, accessible, updated and assessable, with shared activity and outcome indicators.

The Third Sector, and LILT in particular, is a complementary resource to the National Health Service network. Cessation groups, professional training, telephone orientation, collaboration with local services and community presence can help reduce barriers to treatment, especially where specialist services are scarce or poorly known.

22.6 REGULATION, ENFORCEMENT AND ENVIRONMENTS FREE FROM SMOKE, AEROSOL AND NICOTINE

The round table also stressed regulation and enforcement. The ban on sales to minors must be strengthened through effective controls, because student data show that access to products remains possible. At the same time, regulation should address not only sales, but also advertising, flavours, packaging, promotion, visibility in points of sale and digital marketing.

Environments should also be rethought. The objective is not only smoke-free environments, but increasingly environments free from smoke, aerosol and nicotine. Schools, homes, sports settings, healthcare facilities and public spaces should no longer tolerate the idea that electronic aerosol is harmless or socially neutral. Denormalisation remains one of the strongest tools in tobacco control.

22.7 SHARED OPERATIONAL PRIORITIES

The shared operational priorities emerging from the round table can be summarised as follows: strengthen early prevention; protect minors; regulate the appeal of new products; enforce age restrictions; update health-professional training; expand and standardise Smoking Cessation Centres; ensure access to evidence-based medications; integrate LILT and Third Sector resources; improve regional governance; monitor outcomes and rapidly detect adverse events through Poison Control Centres and surveillance systems.

22.8 INTERPRETATIVE CLOSURE

The concluding message of the Conference is that Italy needs to move from describing trends to acting on them. The decrease in conventional cigarette use should not lead to complacency, because nicotine use is changing form, products and target populations. The next phase of tobacco control must therefore be broader, more integrated and more operational: prevention before initiation, treatment after dependence, regulation of the market and governance of services.

KEY MESSAGES

• The decline in conventional cigarette use does not necessarily correspond to a proportional reduction in overall nicotine exposure.
• In 2026, the student surveys document use already in the 11-13-year age group and very high prevalence in the 14-17-year age group.
• Electronic cigarettes are the most widely used product among students; heated tobacco slightly exceeds conventional cigarettes.
• Gender differences require targeted prevention, but trends must be described precisely and not generalised across all ages and products.
• Poly-use is now a central indicator: 51.4% among 11-13-year-old users, 69.5% among 14-17-year-old users and 94.5% among nicotine pouch users.
• Nicotine pouches do not appear to be a substitute product among adolescent users, but rather an additional source of exposure in multi-product profiles.
• Associations with alcohol use, drunkenness, anxiety, depression and lower psychological well-being require integrated interventions addressing dependence and mental health.
• Prevention must integrate school, family, health services, the ISS Quitline, Smoking Cessation Centres and market regulation.
• In paediatric age, screening should include all nicotine-containing products and not only conventional cigarettes.
• New products should not be described as harmless: emerging evidence indicates biological, cardiovascular and respiratory risk signals, especially in dual or multi-product use.
• The Milan Poison Control Centre surveillance shows that acute events involve especially young children, through ingestion, accidental aspiration and sentinel cases related to prefilled devices, HTPs and pouches.
• Cessation should be a structural component of the public-health response, addressing also users of e-cigarettes, HTPs and poly-users.
• The 2026 ISS census indicates that the specialist network is strategic, but needs greater territorial uniformity, rapid access, outcome monitoring, data standardisation and training on new nicotine products.
• Regional governance is decisive: planning, coordination, training, homogeneous access, digital tools and guidelines should transform the network from a list of services into an infrastructure for treatment of nicotine dependence.
• LILT is a historical and operational resource for cessation, through cessation groups, training, SOS LILT and territorial experimentation.
• The concluding round table confirms that the problem is no longer only combustible smoking, but the entire continuum of nicotine exposure.
• The national response must translate trends into action: early prevention, enforcement, treatment access, integration of Smoking Cessation Centres, regional governance and outcome monitoring.
• The public-health agenda is clear: protect minors, counter the appeal of new products, denormalise smoke and aerosol, treat dependence and coordinate institutional, clinical and community networks.

FINAL CONTROL NOTE

In the final review, the main numerical data were checked against available congress sources and authoritative institutional or scientific sources: ISS/EpiCentro, Ministry of Health, WHO, Cochrane, Tobacco Control Scale, Official Gazette, LILT and the Niguarda Poison Control Centre. Information derived from congress recordings was retained as primary conference material; where it was not available in full published form, it was formulated cautiously and without transforming observational associations into causal relationships.

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