Int. J. Environ. Res. Public Health 2009, 6 217 nicotine gum, nicotine inhaler, nicotine nasal spray, and nicotine patch—are effective and at least one of these medications should be prescribed in the absence of contraindications. 5. ARRANGE: Schedule follow-up contact, either in person or via telephone. Encourage relapsed smokers to try quitting again. Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved. There is limited data to guide clinicians in recommending one type of pharmacotherapy over another, the use of combinations, or how to match individual smokers to a particular form of therapy. Recently a Delphi approach was used to build consensus among a panel of international experts from various health disciplines with the purpose of developing decision rules for clinicians to guide differential prescribing practices and tailoring of pharmacotherapy for smoking cessation [89]. Factors that should be considered in prescribing pharmacotherapy include level of scientific evidence, patient preference and patient previous experience. The decision to prescribe combinations should be based on a history of failed attempts with monotherapy, patients with breakthrough cravings despite treatment and level of tobacco dependence. Other factors that should be taken into account on selection of pharmacotherapy include the potential impact on comorbidities and the presence of contraindications. There appears to be good justification for "off label" use such as higher doses of NRT or combination therapy in certain circumstances. 11. What can We Expect in the Near Future? Although recent data suggest that current pharmacotherapy for smoking cessation is superior to placebo for treating nicotine dependence, a majority of smokers fail to maintain long-term abstinence from smoking. Thus, continued investigation of novel medications for nicotine dependence remains a critical priority. Promising agents include new non-nicotine-replacement pharmacotherapies [90-93] such as selegiline (a monoamine oxidase type B [MAO-B] inhibitor), fluoxetine (an antidepressant of the selective serotonin reuptake inhibitor [SSRI] class), naltrexone (an opioid receptor antagonist used primarily in the management of alcohol dependence and opioid dependence) and mecamylamine (a ganglionic blocker); other strategies include the development of a vaccine against nicotine dependence [94] and pharmacogenetic approaches to smoking cessation [95, 96]. 12. Conclusions Tobacco use kills more than five million people a year and accounts for 10% of adult deaths worldwide. COPD is a major and growing cause of morbidity and mortality with smoking being recognized as its most important causative factor. Several meta-analyses have shown that all pharmacotherapies for smoking cessation are twice as likely more efficacious than placebo with an abstinence rate in the 25-30% range at one year when pharmacological treatment and behavioral support are combined. Unfortunately, in spite of the initial efficacy of these pharmacotherapies, the number of patients that remain abstinent from smoking at 1 year follow-up is low (range 16-25%) [64].