On behalf of the American Osteopathic Academy of Addiction Medicine, let me welcome you to this presentation on tobacco-related disorders. My name is Dr. Gregory Landy, and I will be with you as your presenter throughout this presentation. And in that regard, I have no ethical or financial disclosures in regard to this presentation. So during our time together, we're going to review the diagnostic criteria of the tobacco-related disorders. We're going to learn just a little bit about the history of tobacco. We're going to spend some time looking at the impact of tobacco use disorders on health. And we're going to review a common assessment instrument that you can use in your clinical practice. We'll learn about behavioral change, and we'll understand the more common forms of smoking cessation interventions. Now, let's talk a bit about the history of tobacco. It would appear that the first human use of tobacco was quite a while ago, perhaps as long as 10,000 years ago, and was used at that time as part of religious rituals. Moving forward in time quite a bit, Columbus introduced tobacco to Europe. And in fact, by 1573, the tobacco plants were presented to Queen Elizabeth I. During the Industrial Revolution led to the mass consumption of cigarettes. Of course, advertising increased the selling of cigarettes, including rampant portrayals in movies and TV. And then we come to the 1998 Master Settlement Agreement that forever changed tobacco companies and their advertising techniques. This was an agreement between the State Attorneys General and the major U.S. tobacco companies. So let's begin with tobacco use disorder as our first tobacco-related disorder that we'll spend some time with. Now, I know it's painful and tedious, but it's really important that we understand the DSM-5 TR diagnostic criteria. And let's begin by going through this line by line. Criterion A, there's a problematic pattern of tobacco use leading to clinically significant impairment or distress as manifested by at least two of the following occurring within a 12-month period. Tobacco is often taken in larger amounts over a longer period than was intended. Two, there's a persistent desire or unsuccessful efforts to cut down or control tobacco use. Three, a great deal of time is spent in activities necessary to obtain or use tobacco. Four, craving or a strong desire or urge to use tobacco. Five, recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home, such as interference with work. Six, continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco, that is, arguments with others about using tobacco. Seven, important social, occupational, or recreational activities are given up or reduced because of tobacco use. Eight, recurrent tobacco use in situations in which it is physically hazardous, that is, smoking in bed. Nine, tobacco use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the tobacco. And ten, tolerance as defined by either of the following, a need for markedly increased amounts of tobacco to achieve the desired effect, or a markedly diminished effect with continued use of the same amount of tobacco. And finally, withdrawal, as manifested by either of the following, the characteristic withdrawal syndrome for tobacco, referring to criterion A and B, the criteria set for tobacco withdrawal, and B, tobacco or a closely related substance, such as nicotine, is taken to relieve or avoid the withdrawal symptom. Now let's take a look at some of the epidemiology related to the use of tobacco. As you well know, it is the number one preventable cause of disease, disability, and death in the United States. Cigarette smoking causes more than 480,000 deaths per year in the United States. Tobacco use is consistently higher among those with a lower annual household income. And tobacco use is highest in the Midwestern states and the Southern states. It's highest among individuals who are divorced or separated or widowed. And again, it's higher among those with emotional problems. Now here we have a slide that's looking at past month tobacco use or nicotine vaping among people age 12 or older, and this data is from 2022. Now let's look at the circle diagram first, where we see that when we look at no past month tobacco product use or nicotine vaping, that is a population of 218 million people or 77% of the American population. But we're wanting to focus on those 22.7% or nearly 64 million people in the United States who related past month tobacco product use or nicotine vaping. Now if we look at how that breaks down, that past month use is 41.1 million are reporting the use of cigarettes. Now look at the bottom, nicotine vaping, 23.5 million, followed by cigars, smokeless tobacco, and pipe tobacco. Now here we have another slide, this one looking at daily cigarette use. Among past month, meaning current, cigarette smokers aged 12 or older, we smoked one or more packs of cigarettes per day in 2022, latest data. Again starting with the 17 million current use, less than daily smokers, 41.1%. But here we have 24.1 million who are current daily smokers, 58.7%. Breaking that down, 14.5 million smokers are admitting less than a pack per day. While the remaining almost 40% or 9.6 million smokers are admitting to the use of one or more packs of cigarettes per day, pretty hefty amount. Now on this slide, we see the type of past month tobacco product use or nicotine vaping among past month nicotine product users aged 12 or older, again this latest data from 2022. So let's take a moment and study this slide. Among those 12 or older, 63.2% only tobacco, 16.5% nicotine vaping and a tobacco product, while 20.3% nicotine vaping. Now if we break that down into more discrete age groups, let's look at the 12 to 17 year olds, 73.2% are getting their nicotine from vaping, 18 to 25 nicotine vaping is dropping but still is the number one source of nicotine, 48.7% among those ages 18 to 25. Now those 26 years or older, these numbers change quite a bit and we have 74% of individuals in the 26 year or older age group, 74% only tobacco. Now tobacco as we all know is most injurious to an individual's health. Approximately one in five deaths in America are due to cigarette smoking, 90% of lung cancer deaths related to tobacco, 80% of COPD deaths. Smoking increases the risk of coronary heart disease by a factor of two to four and by a similar factor, stroke. Now in the graphic here we see that nearly every organ system is affected, mouth and pharynx, oral cavity, the larynx, acute myeloid leukemia, tobacco use can cause cancer in the kidney and pelvis, uterine cervix and the bladder, the esophagus, of course the lungs, bronchus and trachea, the liver, stomach, pancreatic cancer, colon and rectum. Truly tobacco use can affect every organ system in the body. Now let's take a moment and talk about secondhand smoke. Now with this slide I want to draw your attention to the superscripted number at the top of the slide. And you'll see these numbers throughout this presentation and that refers to the reference at the end of this presentation that you can refer to and learn more about a particular topic. It's the source for the data. But with that in mind, a quote, there is no safe level of exposure to secondhand smoke. Most exposure to secondhand smoke occurs in homes and workplaces. Keep in mind that tobacco smoke contains more than 7,000 chemicals, including hundreds that are toxic and about 70 that are carcinogenic. In children, tobacco smoke contributes to ear infections and respiratory infections. And with that in mind, when you're doing an H&P in this age range and children present with these issues, you should be thinking secondhand smoke. Measurements of cotinine show that exposure to secondhand smoke has steadily decreased, that's good news, in the United States over time and that can be related to policies and prices that have resulted in a decline in use. Now tobacco is big business, no doubt about it. In 2019, tobacco companies spent over $9 billion marketing their products. The ads have been updated and now include electronic cigarettes, e-cigarettes, electronic cigars, yes, there are e-cigars, and electronic pipes, e-pipes. The United States is the fourth largest tobacco producing country in the world, with North Carolina and Kentucky growing more than 70% of the U.S. total based on figures from 2018. Cigarette smoking adds $240 billion in health care spending and another $185 billion in smoking-related workplace productivity losses. Those are staggering numbers. It's also well known from an economic standpoint that a 10% increase in the price of any particular tobacco product decreases use by 3 to 5%. Now let's talk about cigars. In 2023, cigars were the third most commonly used tobacco product, where? Among U.S. middle and high school students. Flavors and single units may increase the sales of cigars. And cigarillos, which have 3 grams of tobacco, no filter, they're about 3 to 4 inches long, accounted for 94% of cigar sales in the United States. Now here's an interesting thing. The hookah, which is a water pipe, it uses a special tobacco flavors to enhance the user's experience. It is not a safe alternative to any other tobacco product. In 2018, believe it or not, 7.8% of high school students reported prior year use of a hookah. And 12.3% in the ages from 19 to 30. Use is greater in the Northeast United States. It also may be higher among college students. And yes, there are electronic hookahs. So keep in mind, the hookah is a source of tobacco. Well, how about smokeless tobacco? This includes chewing tobacco, snuff, and dissolvables, such as lozenges and sticks. Approximately 2.1% of adults aged 18 or older admit current use. And it's almost entirely male. Only 0.2% of females use smokeless tobacco. And approximately 7.9% of smoking cigarettes and using smokeless tobacco together. So they're combining their tobacco products. Smokeless tobacco is most commonly used in the Midwestern and Southern states. Now, let's take a moment and look at where young people are using tobacco. What's going on here? In 2023, approximately 1 out of every 22 middle school students, middle school, 4.6% reported using an e-cigarette in the past 30 days. Approximately 1 out of every 10 high school students reported using an e-cigarette. That's 10%. And in 2023, again, high school level, cigarettes, 1.9%, cigars, 1.8%, nicotine pouches, 1.7%, and smokeless tobacco products, 5%. So the graph basically just emphasizes what we talked about. Current tobacco product use among US high school students is at 12.6%. That's any tobacco product, of which the largest component is occupied by e-cigarettes, which account for 10% of their tobacco use. So what is an electronic cigarette? Well, let's go through some fast facts. E-cigarettes consist of a battery, a heating element, and a liquid. Users inhale an aerosol from heating a liquid that usually contains nicotine and various flavorings. Now, electronic cigarettes are, of course, referred to as e-cigs. We have e-hookahs. We have mods, vape pans, vapes, tank systems, and electronic nicotine delivery systems, ends, and finally, just simply vaping. It's important to keep in mind that these mechanisms may also deliver marijuana and other drugs, not just nicotine. Now, some more fast facts about electronic cigarettes. Even liquids that are marketed as no nicotine, surprise, surprise, when analyzed may very well have nicotine. Now, there are some rather potent hazards of the electronic cigarette aerosol, and that includes the inhalation of ultra-fine particles, dangerous additives, heavy metals, and the presence of volatile organic compounds. Now, some more information about electronic cigarettes. I put it in bold. It's the number one youth tobacco product. It bears repeating. Electronic cigarettes are the number one youth tobacco product. In 2023, looking at past 30-day use, 4.6% of middle school students and 10% of high school students fell into that group. 25.2% of those categories reported using e-cigarettes daily. Now, disposable e-cigarettes, perhaps not unsurprisingly, were the most commonly reported device type used, nearly 61%. 89.4% in this youth tobacco product category reported using a flavored product during the past 30 days. Now, despite the news that has really focused on menthol among the youth market, the top reported flavor categories were fruit, 70.5%. Candy flavors, 39.8%. Mint, 32%. And menthol, 18.7%. Of course, they're choosing multiple categories. Let's take a moment and go through a clinical scenario, a break in all these facts. You see a 34-year-old female, and she wants to quit smoking. She's tried nicotine replacement products, but after a short abstinence, she resumed smoking. You recommend varinicline, but she adamantly refuses medications. She counters by wondering if e-cigarettes can help her quit smoking. How should you educate this patient? Well, again, a reminder about the numbers for the references for this particular clinical scenario's answers. E-cigarettes are not approved by the FDA as a quit smoking aid. The United States Preventive Services Task Force, and I quote, the evidence on the use of e-cigarettes for tobacco smoking cessation in adults, including pregnancy, is insufficient. While, quoting, e-cigarettes may help non-pregnant women who smoke it if used as a complete substitute for all cigarettes and other smoke tobacco products. But the task force underlines that more research is needed to balance the risks and the benefits. But let's keep in mind that e-cigarettes are not approved by the FDA as a quit smoking aid. Now let's turn our attention to the other tobacco related disorder that we're gonna talk about during our time together and that's tobacco withdrawal. And again, as before, let's go through the DSM-5-TR diagnosis line by line, beginning with criterion A, which requires the daily use of tobacco for at least several weeks. Criterion B requires the abrupt cessation of tobacco use or reduction in the amount of tobacco use, followed within 24 hours by four or more of the following signs or symptoms. The signs or symptoms include irritability, frustration or anger. Two, anxiety. Three, difficulty concentrating. Four, increased appetite. Five, restlessness. Six, depressed mood. And seven, insomnia. So again, keep in mind, tobacco withdrawal requires the abrupt cessation of tobacco use or reduction in the amount used, followed within 24 hours or more of the following signs or symptoms. Four or more. Now let's take a few moments and talk about the management of tobacco related disorders. And we're gonna cover this topic by looking at some general principles, briefly touching on motivational interviewing and spending a bit more time on pharmacotherapy. Now, again, drawing from the U.S. Preventive Services Task Force on the Interventionists for Tobacco Smoking Cessation, the goal is to ensure that every patient is screened for tobacco use. Tobacco use status is documented, and the patient who uses tobacco, they are advised to quit. Followed by offering the patient's cessation medication unless it's contraindicated, counseling and assistance, as well as arranging follow-up contact, either on-site or through referrals to the state quit line or other community resources. The task force has summarized this with the five A's. Ask about tobacco use. Advise to quit. Advise to quit. Assess willingness to make a quit attempt. Assist in the quit attempt. And arrange follow-up. So the five A's for tobacco smoking cessation as recommended by the task force, ask, advise, assess, assist, and arrange. Now, the task force also recommends that when it comes to pregnant women, use multiple choice questions. And that will more likely give you the historical perception. Now, stages of change can be considered really the first step in management when it comes to smoking cessation. You really wanna know where the individual's at in terms of quitting. So let's go through these stages of change. We first have pre-contemplation, which they really have no serious thoughts of change. And in fact, they may be unaware of any particular problem. We next have contemplation, where they may be considering change, but they're ambivalent. They're aware of the problem. Preparation. Here, there is some effort to change, but the cons of change still outweigh the pros. They're making some steps towards change. In the action stage, they're actually taking steps to change. They practice the desired behavior, but it's important to keep in mind that even during the action stage, the individual will be confronting ambivalence. Maintenance. They're able to handle the urges, and they're beginning to solidify their quit smoking behaviors. But keep in mind that relapse is a stage of change. It's an opportunity to learn and to help the individual begin the process anew. It's not a failure. It's an opportunity to learn. Now, when it comes to counseling for tobacco cessation, there are different psychotherapeutic options that individual practitioners can take advantage of. We have behavioral treatments. Behavioral treatments provide practical strategies involving the triggers that would lead an individual to want to use a tobacco product, help the individual with their cravings, and withdraw symptoms. Cognitive therapy, which includes cognitive behavior therapy is the most well-researched in this area. Motivational interviewing is another approach. This is a patient-centered therapy. It's non-confrontational. It's designed and practiced to be non-judgmental, and it's highly collaborative. It's a very patient-centered approach. We have contingency management, where incentives such as money or other tangible items or rewards, if you will, are to help motivate people to change their behavior. And then let's not forget brief interventions, which are meant to be three minutes or more. Brief interventions, and there's research to support this in reducing the individual's smoking. It increases quit rates. And brief interventions can consist of congratulating the patient on any success, no matter how many. You want to encourage their march towards abstinence. You may take some time to discuss the health benefits they're achieving. You do want to, if there are any problems that the patient is encountering in their quit smoking therapy, you can talk about that too as point of resistance, and again, helping the individual move on and up. Now here, I want to draw your attention to the Fagerstrom nicotine dependence scale. This is a self-administered instrument that you can readily adopt in your clinical practice, and it can also find a use when you begin prescribing certain pharmacotherapies. So there are two versions here. We have an adult version, and we have one that's designed for those 14 to 20 years of age. Now the adult version consists of six questions. And do you currently smoke cigarettes? How soon after you wake up do you smoke your first cigarettes? Do you find it difficult to refrain from smoking in places where it is forbidden? Which cigarette would you hate to give up? How many cigarettes per day do you smoke? And do you smoke more frequently during the first hours after awakening than during the rest of the day? And do you smoke when you're so ill that you are in bed most of the day? Now, I've included the scoring template at the bottom. You can see that the individual scores eight or higher. That would suggest a high level of nicotine dependence. Now, alternatively, we have a scale for those ages four to 20, which is a modified version of the Fagerstrom tolerance questionnaire. Here we add one additional question. Beginning with how many cigarettes a day do you smoke? Do you inhale? How soon after you wake up do you smoke your first cigarette? What cigarette would you hate to give up? Do you find it difficult to refrain from smoking in a place where it's forbidden? Do you smoke if you're so ill that you're in bed most of the day? And finally, do you smoke during the first two hours during the day? So those seven questions can be scored in a way that indicates six to nine, meaning that they have a substantial nicotine dependence. Now, let's turn our attention to some interventions. And we're gonna begin with nicotine replacement therapy. So clearly what we're doing here is we're providing nicotine without the ostensible harmful combustion products. Higher doses and two combination of nicotine replacements may actually increase the quit rates. It's something to keep in mind. Nicotine replacement therapy is really more effective for those at the higher scale of use, greater than 15 cigarettes per day. You can even suggest nicotine replacement therapies at periods of greatest craving, which as a Figerstrom scale would help you identify such as upon awakening, when of course their nicotine level is at the lowest point. Nicotine replacement therapies increase the chances of successfully quitting by 50 to 70%. And the forms that we're gonna be talking about all have similar efficacy. There are five FDA products that we're gonna mention, gum, lozenge, patch, nasal spray, and oral inhaler. Let's begin with nicotine gum. It comes in two forms, two milligrams and four milligrams, and it can come in some flavors, cinnamon, fruit, mint. There are some precautions with nicotine gum you need to keep in mind, such as a recent, meaning two weeks or less, myocardial infarction, serious underlying arrhythmias, serious or worsening angina, temporal mandibular joint disease, pregnancy and breastfeeding, and adolescents less than 18 years of age. So how do you dose nicotine gum? Well, if their first cigarette is less than 30 minutes after they awake, they should be taking the four milligram version. If it's a bit later, 30 minutes after they awaken, they can take the two milligram. From weeks one to six, they take one piece of gum every one to two hours. Weeks seven to nine, one piece every two to four hours. And weeks 10 to 12, it's one piece every four to eight hours as you taper it down. Remind the individual the maximum is 24 pieces per day. Now, in addition to dosing, it's very important that the individual use the nicotine gum properly. They need to chew each piece slowly, and they need to park it between the cheek and the gum. When they feel a peppery or tingling sensation. And that appears after they've chewed it, say 15 to 30 times. Now they resume chewing when the tingle fades. And it's recommended that they repeat this chew in part until most of the nicotine is gone, which means they no longer have that tingling sensation, and that can take up to 30 minutes. It's also advisable to park the gum in different areas of the mouth. No food or beverage 15 minutes before or during use. And nicotine gum can be used up to 12 weeks. Now let's talk about nicotine lozenges. They also come in two and four milligram varieties, cherry and orange. Two and four milligram varieties, cherry and mint flavors. Similar precautions. A recent less than two weeks of a myocardial infarction, serious underlying arrhythmias, serious or worsening angina, pregnancy and breastfeeding, and adolescents 18 years of age or younger. And the dosing for the lozenges follows a similar pattern as with the gum. If the first cigarette is used 30 minutes, less than 30 minutes after they awake, the four milligram dose would be appropriate. If it's later, meaning the first cigarette was after 30 minutes, they can get by with the two milligrams. Again, a similar tapering. Weeks one to six, it's one lozenge every one to two hours. From week seven to nine, it's one lozenge every two to four hours. And from weeks 10 to 12, one lozenge every four to eight hours. The maximum 20 lozenges per day. Now again, the means by which the product is used is important. You need to allow the lozenge to slowly dissolve, 20 to 30 minutes. For the standard lozenge, there is a mini version that can take 10 minutes. The nicotine that's being released may cause a warm tingling sensation, but it's important not to chew or swallow the lozenge. It's also a good idea to rotate to different areas of the mouth. And again, as with the gum, no food or beverage 15 minutes before or during use. The duration for lozenge, up to 12 weeks. Now let's turn our attention to the transdermal nicotine patch. And it comes in a seven milligram, 14 milligram, and 21 milligram patch, 24 hour release variety. Again, similar precautions. A recent, less than two weeks, myocardial infarction, serious underlying arrhythmias, serious or worsening angina, pregnancy, prescription formulations, category D, and breastfeeding, and adolescents, 18 years of age or younger. The dosing. If they're taking more than 10 cigarettes per day, they should start with a 21 milligram patch daily for four to six weeks. Tapered to 14 milligram daily patch for two weeks. And then a seven milligram patch for four to six weeks. And then a 14 milligram daily patch for two weeks. If they're smoking less than 10 cigarettes per day, you would start with a 14 milligram daily patch for six weeks, followed by the seven milligram patch daily for two weeks. Now it's important in terms of how the patch is used to rotate the application site daily. And it would not be advisable to apply a new patch to the same skin site for at least a week. You should use the patch for 16 hours. If the patient experiences problems with their sleep, you can remove it at bedtime. And the duration of use for the patch between eight and 10 weeks. Now the nicotine nasal spray, of course, is a prescription product. It's a metered spray, 10 milligrams per milliliter aqueous solution. Again, the precautions, a little bit different here. Again, the recent less than two weeks myocardial infarction, serious underlying arrhythmias, serious or worsening angina. But again, because it's a nasal spray, it would be a precaution about any underlying chronic nasal disorders such as rhinitis, nasal pulps or sinusitis, severe restrictive airway disease, pregnancy is category D and breastfeeding. And again, adolescents 18 years and younger. The dosing for the nicotine nasal spray is one to two doses per hour or eight to 40 doses per day. You do one dose, which equals two sprays, one in each nostril. Half a milligram of nicotine is delivered to the nasal mucosa. The maximum is five doses an hour or 40 doses a day. And for best results, they should initially use at least eight doses a day. It's important to instruct the patient not to sniff, swallow or inhale through the nose as the spray is being administered. And the nicotine nasal spray can be used from three to six months. And finally, let's talk about the nicotine oral inhaler. Also a prescription product. It's provided with a 10 milligram cartridge that can deliver four milligrams of vapor. Again, the precautions, recent, less than two weeks, myocardial infarction, serious underlying arrhythmias, serious or worsening angina, angina, bronchospastic disease, pregnancy, it's a category D in breastfeeding, and adolescents less than 18 years of age. So how do you dose the nicotine oral inhaler? Well, it's six to 16 cartridges a day. You're gonna individualize it for the patient. It's recommended to initially use one cartridge every one to two hours. Now the best effects are gonna be achieved with continuous puffing for about 20 minutes. And the individual should initially use at least six cartridges a day. Now the nicotine in the cartridge is depleted after approximately 20 minutes of active puffing. Now again, it's important to instruct the patient on the proper use of the inhaler. You want to advise the patient to inhale into the back of the throat or puff in short breaths. Despite the name, you do not inhale into the lungs like a cigarette, but you puff as if lighting a pipe. Now an open cartridge can retain its potency for 24 hours. And with the other similar oral products, no food or beverages 15 minutes before or during use. And the nicotine oral inhaler can be used from three to six months. Now let's move away from the nicotine replacement therapies and talk about two medications. Now we're gonna start with bupropion. And here we're talking about the 150 milligram sustained release tablet. There are some important precautions to keep in mind when using bupropion as a smoking cessation aid. You have to keep in mind any concomitant therapy with medications, particularly those known to lower the seizure threshold. Hepatic impairment, another consideration. Pregnancy, bupropion is a category C in breastfeeding. Again, adolescents less than 18 years of age. Treatment emergent neuropsychiatric symptoms. That boxed warning was removed in December of 2016. Now there are actually contraindications to the use of bupropion in smoking cessation. One of which would be a seizure disorder. Another would be a concomitant use of bupropion in an alternate form such as well, butren or depression, if you will. Current or prior diagnosis of bulimia or anorexia nervosa. Simultaneous abrupt discontinuation of alcohol or sedatives, benzodiazepines, and monamine oxidase inhibitors during the preceding 14 days of current use of reversible monamine oxidase inhibitors. So, surpassing those contraindications, how do you use bupropion? It's 150 milligrams by mouth every morning for three days. Then it's 150 milligrams by mouth twice a day. You do not exceed 300 milligrams a day. You begin the therapy one to two weeks prior to their established date. You need to allow at least eight hours between the doses and avoid bedtime dosing to minimize any subsequent insomnia. Dose tapering is not necessary. The duration of treatment of bupropion can be seven to 12 weeks, and with maintenance up to six months in selected patients. Now let's talk about vernicolin, otherwise known as Chantix, which comes in a half milligram and one milligram tablets. And as with the other medications, certain precautions to keep in mind with vernicolin. Severe renal impairment will require a dosage adjustment. In terms of pregnancy, it's category C in breastfeeding. Again, adolescents less than 18 years of age. And we're gonna talk about this a bit more, but the treatment of emergent neuropsychiatric symptoms that plagued vernicolin, that box warning was removed in 2016. So dosing of vernicolin on days one to three, the individual will take a half a milligram by mouth every morning. On days four to seven, it's a half a milligram twice a day. On weeks two to 12, it's one milligram twice a day. It's advised to begin therapy one week prior to their established quit date. And you wanna take the dose after eating and with a full glass of water to minimize the side effects. Dose tapering is not necessary. And the dosing adjustment is necessary again for any individuals that you contemplate prescribing vernicolin to that have severe renal impairment. Vernicolin is usually prescribed for 12 weeks with an additional 12 week course that may be prescribed for use in selected patients. You can initiate vernicolin up to 35 days before the target quit date. They may reduce smoking over a 12 week period of treatment prior to quitting and continue treatment for an additional 12 weeks. Now, how do these two medications work? So quoting, vernicolin is a partial agonist at the alpha four beta two neuronal nicotinic acetylcholine receptor. As a partial agonist, it relieves craving and withdrawal, but reduces the reinforcing effects of nicotine by blocking dopaminergic stimulation. So there's less smoking reinforcement and reward. Bupropion affects dopamine, norepinephrine and nicotinic cholinergic receptors to decrease cravings and withdrawal symptoms. And keep in mind that bupropion may also reduce weight gain associated with smoking cessation. Now let's talk about vernicolin and some published research. An analysis of more than 5,000 smokers without current psychiatric history who participated in a placebo-controlled clinical trials reported there was no significant increase in overall psychiatric adverse events aside from sleep disorders. In another research report, the authors conducted a retrospective analysis of 80,600 adults that were prescribed vernicolin. Depression and suicide was not greater with vernicolin with NRT or bupropion. But based on those clinical findings, the FDA removed the boxed warning for serious mental health side effects from the Shantix drug label. All right, so now we're at the point where we can pivot and take a more lighthearted approach to this presentation and move away from the facts and the figures and the recommendations and put some of our knowledge to use in some clinical scenarios with these practical application quizzes. So let's get started. During a routine checkup, a 42-year-old man mentions a recent increase in shortness of breath, especially during physical activity and a persistent cough in the morning. He expresses concern about his smoking habit and its impact on his health, especially given his family history. The patient himself has a history of controlled hypertension, a normal lipid panel, and an A1c of 5.7%. His father died of a heart attack at age 60. His mother is living, but she has COPD. He reports a 30-year history of smoking one pack of cigarettes per day, two to three alcohol drinks on weekends, and he denies any illicit drugs. He's interested in quitting smoking and has tried multiple times in the past without long-term success. So based on this clinical presentation, what would be a reasonable next step? Would it be, A, prescribe a nicotine replacement therapy to address his nicotine use? Or B, should you order a pulmonary function test to assess the extent of potential lung damage? Or C, should you inquire about his past attempts to quit smoking, including methods used, duration of abstinence, and reasons for relapse? Or perhaps D, advise the patient to reduce the number of cigarettes he smokes per day gradually as a method to quit smoking? Or E, should you schedule the patient for a chest X-ray to rule out any underlying lung pathology? So based on that clinical history, what would be a reasonable next step? Based on that clinical history, what would be your next step? Well, in this particular scenario, it would probably be best to inquire about the patient's past attempts to quit smoking, including any methods used, the duration of the abstinence, and the reasons why he relapsed. Now, the patient here has tried many different ways to quit smoking. He tried the nicotine gum and the lozenge, but he found them both unpleasant and expensive. He's not interested in the nicotine patch because of concerns about the skin irritation. So given where the patient's at, and with a patient-centered approach, what's the most appropriate next step you would consider? Would it be to encourage the patient to reconsider the nicotine patch, assuring him that the skin irritation is generally mild and can be managed? Or B, prescribe a non-nicotine medication for smoking cessation, such as bupropylene or verinicillin. Or perhaps C, advise the patient to continue using nicotine gum and lozenges as they are really the only remaining options. Or D, recommend alternative forms of nicotine delivery systems like e-cigarettes. But given this patient's additional clinical history and his reservations, what is the most appropriate next step? Prescribe a non-nicotine medication for smoking cessation might be a reasonable next step, such as bupropylene or verinicillin, because that may help reduce his cravings and help with withdrawal symptoms. Now, considering the patient's smoking, you decide to discuss non-nicotine pharmacotherapy options. Now, which of the following statements about bupropion is most accurate and should be included in your education to the patient? A, bupropion is a nicotine agonist that will provide a similar experience to smoking, which helps in reducing cravings and withdrawal symptoms. Or would you advise B to the patient, telling the patient bupropion is an antidepressant that requires several weeks to start working and cannot be used in conjunction with nicotine replacement therapies? Or would you educate the patient about C, bupropion should only be prescribed to patients who've been diagnosed with depression and are concomitantly trying to quit smoking? Or would you advise the patient that bupropion is an atypical antidepressant that reduces cravings and has the added benefit of potentially reducing the weight gain often associated with smoking cessation? Or might you then, in selection E, say that bupropion carries a high risk of severe cardiovascular side effects and should only be used as a last resort after other therapies have failed? So which of these is the most accurate and would be most useful in educating this patient? Well, the answer is D. Bupropion is an atypical antidepressant that reduces cravings and has the added benefit of potentially reducing the weight gain that's often associated with smoking cessation. Now, the patient inquires about any potential contraindications to taking bupropion. Now, which of the following answers would you provide the patient? In other words, which of the following choices is a potential contraindication? Mild anxiety disorder, or B, controlled hypertension, or C, the patient's alcoholism, or D, a history of a seizure? Which of the following is a potential contraindication to taking bupropion? If you selected D, a history of a seizure, you are correct. Now, the patient inquires about the dosing. Now, the patient inquires about the dosing portion of the treatment for bupropion. It's a reasonable question from a patient. And the best response from the selections below would include what information? Would you tell the patient A, to take 300 milligrams once daily in the morning, continue for four weeks, then assess for dose adjustment? Or would you advise the patient that they'll be taking 100 milligrams three times a day, with a gradual increase to 100 milligrams five days, five times a day as tolerated? Or C, advise the patient that they will be taking 150 milligrams every morning for three days, then 150 milligrams twice a day for seven to 12 weeks, with maintenance up to six months in selected patients? Or would you advise the patient with selection D, that they will be taking 200 milligrams in the morning, and 200 milligrams in the evening, with dose adjustments every two weeks, based on their response? So which of those would provide the most useful and accurate information to the patient about the dosing of bupropion? So if you select an answer B, you would be correct by noting and educating the patient that they will be taking 150 milligrams once daily in the morning for three days, all by an increase to 150 milligrams twice daily for seven to 12 weeks. There will then be the possibility of maintenance therapy for up to six months in selected patients. Now, your next question in education is in terms of dosing with veriniculin. And again, in terms of educating the patient and prescribing, which is the best answer? A, start with one milligram in the morning for the first week, then increase to one milligram twice a day from the second week onward. Or would you tell the patient B, begin with a half a milligram twice a day for the first three days, then increase to one milligram twice a day for the remainder of the treatment course? Or would you recommend C, initiate treatment with a half a milligram in the morning on days one to three, then a half a milligram twice a day on days four to seven, and then continue with one milligram twice a day from weeks two to 12? Or finally, would you choose D, take a half a milligram once daily for the first four days, followed by an increase to half a milligram in the morning and evening for the next three days with no further dose increases? So what is the best dosing for veriniculin? If you chose C, you would be correct in recommending to the patient that they would initiate treatment with a half a milligram in the morning on days one to three, then a half a milligram twice a day on days four to seven, and they will continue with one milligram a day from weeks two to 12. Now, based on, this is a true or false question, straightforward. Now, based on, this is a true or false question, straightforward. Based on clinical trials, the FDA removed the boxed warning for serious mental health side effects from the Shantix drug label. Is that true or false? And of course, as we've learned during this presentation, the answer to that question is indeed true. Now, here we have another clinical vignette. During a comprehensive health education class at a local school, you present a module on the risk associated with smoking and other forms of tobacco use. This module covers various topics, including the history of smoking, health effects, societal impacts, and the rise of new tobacco products. After discussing the harmful effects of traditional cigarettes you shift the focus to modern challenges in tobacco use prevention among youths. The class examines statistics, case studies, and current trends to understand how the landscape of tobacco use has evolved, particularly with the advent of tobacco and new products. Given this scenario, which of the following should be considered the main product attracting youth to tobacco use today? Is it A, traditional cigarettes due to their historical popularity and image? B, chewing tobacco because of its discreet use and varied flavors? C, hookahs due to the social aspect and perception of being less harmful? D, cigars, particularly those with flavorings that appeal to younger demographics? Or E, e-cigarettes because of their appealing flavors and perceived lower health risks? If you chose e-cigarettes, you would be correct. Now, you're conducting a lecture on the principles of preventive care and during the lecture, you emphasized the importance of the five A's model for tobacco screening and intervention in primary care as recommended by the U.S. PreventAid Services Task Force. This model is designed to help clinicians effectively engage with patients in discussions about healthy behaviors. To illustrate the point, you present a case study involving a patient who smokes and has come in for a routine checkup. Following the task force recommendations, which sequence of actions represents the five A's models that healthcare providers should take to address the smoking behavior effectively during that visit? Is it A, analyze, advise, add, answer, and adhere? Or B, acknowledge, advise, assess, arrange, and account? C, ask, alert, appraise, assist, and acknowledge? Or D, ask, advise, assess, assist, and arrange? If you choose answer D, ask, advise, assess, and arrange, then you would be correct. Ask about tobacco use, advise to quit, assess willingness to make a quit attempt, assist in the quit attempt, and arrange follow-up. You next discuss the stages of change model. To bring your theory into practical application, you present an interactive case study to the medical students. The scenario features a patient who has been a smoker for 15 years and is seeing their primary care physician for an annual checkup. The physician's goal is to guide the patient through the process of quitting smoking. Using the stages of change model, you ask the students to identify the correct order of stages that the patient might progress through in their journey towards cessation of smoking. Is it A, realization, willingness, preparation, implementation, persistence, and reversion? B, acknowledgement, deliberation, intention, execution, sustenance, and regression? C, pre-contemplation, contemplation, preparation, action, maintenance, and relapse? Or D, consideration, readiness, initiation, movement, continuation, and setback? If you said C, pre-contemplation, contemplation, preparation, action, maintenance, and relapse, you would be correct. Now you're educating a patient on the correct use of nicotine gum as part of a smoking cessation program. The patient has been a smoker for several years and is motivated to quit. You understand the importance of proper technique to ensure the efficacy of nicotine gum and minimize side effects or incorrect usage. Which of the following instructions should you give the patient? A, chew the gum rapidly for five minutes and then swallow it to release the nicotine quickly into the system. B, chew the gum continuously until the flavor is gone, then discard it immediately after. Or C, chew the gum slowly and upon feeling a tingling sensation, park it between the gum and cheek until the tingling fades and resume chewing. Alternate the parking areas on the map. Or D, chew the gum until it becomes soft and then place it under the tongue for faster absorption of the nicotine. And of course, you would answer C, the chew and park methodology. So in summary, during this presentation, we reviewed the diagnostic criteria for tobacco-related disorders. We reviewed briefly the history of tobacco. We discussed the impact of tobacco-related disorders on health. We reviewed a common assessment instrument you can use in your clinical practice. And we learned about the stages of change and various counseling interventions. And finally, we reviewed nicotine replacement therapies, bupropion and baroniclin as part of an integrated approach to smoking cessation. These are the references that were used to prepare this presentation and that you can refer to. And so with that, thank you for listening to this presentation on tobacco-related disorders. On behalf of the American Osteopathic Academy of Addiction Medicine, and best wishes in your future clinical practice.

tobacco-related disorders

Dr. Gregory Landy

American Osteopathic Academy of Addiction Medicine

tobacco use epidemiology

smoking cessation interventions

nicotine replacement therapy

secondhand smoke risks

behavioral change strategies

pharmacotherapy options

electronic cigarettes