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Updates in Treating Tobacco Use Disorder
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Hello and welcome. I'm Amy Cohen, Associate Director for SMI Advisor and a clinical psychologist. I am pleased that you're joining us for today's SMI Advisor webinar, Updates in Treating Tobacco Use Disorder. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Dr. Jill Williams. Dr. Williams is Professor of Psychiatry and Director of the Division of Addiction Psychiatry at the Rutgers University Robert Wood Johnson Medical School in New Brunswick. She also holds faculty appointments at the Cancer Institute of New Jersey and the Rutgers Center for Alcohol Studies. The focus of Dr. Williams' work has been in addressing tobacco in individuals with mental illness or other addictions through treatment and systems interventions. Dr. Williams, thank you for leading today's webinar. Thank you and good afternoon, everyone. This is just my disclosure information. I'm going to give a brief overview of updates in tobacco treatment, summarizing some of the epidemiology with consequences relevant especially to people with serious mental illness. I'll talk about basic techniques for assessment and treatment of tobacco, including pharmacotherapies and identify tobacco treatment for groups in need for behavioral services development in the behavioral health treatment setting. Some of you may be surprised that smoking rates in the United States are at an all-time low. Less than one in five Americans currently smoke cigarettes. There's a little bit of variation from state to state, but most recent estimates are a little less than 14% smoking prevalence rate. Rates have been shown to be much higher among populations with mental illness or substance use disorder. If we say that the population estimate is about 20% and truly it's less than that at this point, we know that estimates for people with mental disorders are on average about double that and they can be as high as triple that among populations with substance use disorders. There's a great disparity there. In fact, when we think about those people that continue to smoke in the United States, it's some of our most vulnerable populations that are affected. Smoking is highly concentrated not only in those with a behavioral health condition, but in low-income populations, those that are underinsured, unemployed, and with lower levels of educational attainment. So we can really think about smoking as a social justice issue. Despite declines in tobacco use, it's still the number one cause of preventable death in the United States. It's responsible for about a third of all cancer deaths. And you can see that tobacco affects nearly every organ of the human body. It causes a large variety of different cancers, but also contributes to many chronic diseases, including cardiovascular disease, a hip fracture, et cetera. There's an old saying that it's the smoke that kills, and this is really a highly relevant statement because, in fact, cigarette smoke is highly toxic to the human body with estimates of thousands of chemical components, most of which are toxic to the human body. Nicotine, of course, is only one component of cigarette smoke and probably one of the least dangerous aspects of cigarette smoke. Smoke is also noted to contain more than 65 different types of cancer-causing agents, so the toxicity is quite tremendous. In thinking about where these different chemicals come from, it's important to recognize that although nicotine is naturally occurring in the tobacco plant, there are other things that end up in cigarettes that are also naturally occurring in the plant, and an important one is called nitrosamines. Nitrosamines are a potent carcinogen responsible for a lot of tobacco-caused cancers, and the idea that nitrosamines are naturally occurring in the plant helps us underscore that there's a risk of cancer from all forms of tobacco use. You can't really separate the two because the carcinogen is essentially in the plant, at least one of them. During the cigarette manufacturing process, chemicals are added that change the way that cigarettes taste, the way they smell, the way they burn, different flavoring agents are added, and this is a source of some of the additional chemicals in smoke, but most of the chemicals come from when you actually light tobacco on fire. When you burn things, you create new chemicals, and that's the source of many toxins that are found in cigarette smoke, including carbon monoxide, formaldehyde, etc. In addition to health consequences, tobacco is associated with many other consequences that impact negatively on people's lives. I would argue that tobacco is a barrier to recovery and community integration, especially among people with behavioral health conditions. The reason is because if you use this drug, you will often experience additional financial hardships. You may find more difficulty obtaining employment and maintaining employment. It's harder to find housing if you're a smoker. There's also now considerable evidence that smoking contributes to poor mental health and increases the relapse back to drugs and alcohol in people who are trying to quit those substances. There's the stigma of being a smoker. Then you can think about the way it negatively impacts appearance and is also the number one cause of fires in the home, lethal fires. Sometimes it's important to consider all the different consequences that people experience from this drug. It's important in counseling people about any substance use disorder. Different consequences are important to different people. If you find that your clients are not so interested in the health outcomes, sometimes it's more useful to talk about some of these more immediate ways that tobacco is negatively impacting their lives. National and international strategies for addressing tobacco include a whole range of public health interventions. I won't really talk about these today, but just to make you aware, they include educational efforts, increasing the price of cigarettes through taxes is an important strategy that reduces tobacco use, as well as age restrictions. Policies that restrict tobacco in the environment have also been highly effective in reducing overall tobacco use rates in this country, as well as support for treatment and cessation efforts. A recent study was conducted by the CDC examining rates of tobacco treatment among U.S. mental health and substance abuse treatment facilities. This was a recent analysis published in 2018, which indicated that less than half of U.S. mental health treatment facilities reported screening patients for tobacco use. It's really amazing that even now in modern times, we're doing a poor job in behavioral health, in even screening patients for tobacco use. This is a key first step, because if we're not asking about tobacco, it's very unlikely that we're providing additional interventions. And you can see that the rates for those are lower still, and quite similar in substance abuse treatment facilities. So we certainly have a lot more to do. There's also now considerable evidence that tobacco is associated with worse mental health outcomes. Conversely, when people quit smoking, we know that they experience improvements in mental health. This was a meta-analysis that looked at this over several studies and showed that when people quit smoking, that they generally experience reductions in levels of anxiety and depression, as well as stress, and over time report better quality of life and better mood in response to quitting smoking. Nicotine, of course, is a naturally occurring alkaloid. It stimulates acetylcholine receptors in the body, has some stimulant-like effects. It's rapidly delivered to the brain when smoked and also has a short half-life, which helps us understand why people have to continuously use this drug throughout the day. Of course, it's important to say this explicitly, that this is a drug, that nicotine impacts the brain and the brain reward pathways much in the same way as heroin and cocaine. We know a lot nowadays about the biology of addiction and the way the brain is impacted by drug use, and nicotine certainly meets all these criteria of being a drug. That's why tobacco use disorder is in the DSM as a behavioral health condition, because it's an addiction, and therefore within the scope of practice of all people who work in behavioral health. Route of delivery is really an important concept in understanding drug addiction, and smoking a drug is really among the fastest ways that you could deliver a drug to your body and to your brain. Smoking a drug and the rapid delivery that occurs through absorption through the lung and the capillaries delivers a large amount of drug, which has a very short distance to travel to reach the brain, and therefore is one of the fastest ways to deliver drug and contributes to the experience of its addicting potential. The speed and delivery and amount of drug that delivers the brain are important properties in understanding how addicting something is, and that rapid speed of delivery that comes from smoking helps us understand why cigarette smoking is such a highly addicting behavior, and you can see that those routes of delivery are much faster compared with snorting a drug, for example, or ingesting a drug orally. In terms of assessment, there's one question that seems to be quite helpful in terms of understanding level of nicotine dependence severity, and it's part of the heaviness of smoking index. I generally recommend that we ask all tobacco users how many minutes in the morning until they smoke their first cigarette. This is referred to as the TTFC or the time to first cigarette, and it's a highly useful measure for helping us understand both the level of severity of nicotine dependence that the person experiences and also has implications for treatment outcome. Anyone that smokes in the first 30 minutes of waking up is at least moderately nicotine dependent, and that's a good indicator of somebody who would benefit from the use of medication. Nowadays, we use medication really in almost all different types of tobacco users, but in particular, we would really want to ensure that people who smoke in the first 30 minutes of waking up in the morning use medication because it's very likely they're going to experience some significant tobacco withdrawal symptoms when they try to quit. When we ask this question to populations with behavioral health conditions, it's not uncommon for people to report that they smoke, in fact, in the first five minutes of waking up in the morning, which is an indicator of a higher level or more severe dependence. In fact, studies show now that people wake up in the middle of the night to smoke, which indicates even a higher level of dependence, and of course, this is because of the short half-life of nicotine. So while people are sleeping in the night, their drug level of nicotine is rapidly going down such that they wake up every morning in withdrawal from this drug. The more addicted somebody is, of course, the more difficulty they may have in quitting. And various studies of people with depression, people with schizophrenia, people with substance use disorders have shown higher levels of dependence compared with other populations. So for example, on the right, we have a population survey of smokers with depression, and we can see that smokers with depression report higher levels of dependence compared with smokers without depression. More of them smoke in the first five minutes of waking up in the morning, and they smoke more cigarettes per day. This has been similarly shown in samples with substance use disorder and schizophrenia. Within hours of someone's last cigarette, they can develop symptoms of tobacco withdrawal. These symptoms can last for a period of at least weeks and contribute to a lot of relapse back to smoking. It's important to be able to recognize the symptoms of tobacco withdrawal. They include sad or depressed mood, insomnia, irritability, frustration or anger, anxiety, trouble concentrating, restlessness, and increased appetite or weight gain. Sometimes there's difficulty in recognizing these symptoms in a behavioral health setting, and you can imagine that they could be missed because they are somewhat nonspecific and may overlap with other behavioral health syndromes. In terms of thinking about what's new, there's a few ways to think about this. Some of the messaging is new in terms of engagement of people. How can we reach people who continue to smoke despite strong public health messages? I'll speak a bit about that in terms of motivating populations and messaging. Similar to that, we can think of alternative language that we don't just frame things in terms of cessation, that we give people a variety of options, that we think about a range of treatment options for addressing this as a substance use disorder. We may encourage people to reduce, to quit, or to even try quit for a day, different strategies targeting engagement. There's ways that we can do more aggressive pharmacotherapy perhaps than in the past, and we need to continue to work to increase access to pharmacotherapy since this is an essential part of an effective treatment plan. In terms of selecting pharmacotherapy, there are some new ideas in terms of metabolism, illness characteristics that may... This is still in the research phase, but may lend itself in the future to more selective matching in terms of best treatments. Of course, there's a rapid increase in access to these alternative products, alternatives to cigarettes, so-called noncombustible products which deliver nicotine but don't burn. I'll say a little bit about each of these. As we're helping people to quit smoking or quit using tobacco, these are predictors of abstinence, so if you have a lower level of dependence or higher socioeconomic status, if you're an older age, if you have no behavioral health comorbidity. Those are all factors that make it easier to quit smoking, so you can see our patients experience some challenges in terms of their behavioral health comorbidity. It's not impossible for them to quit, but it is perhaps more challenging than in populations without behavioral health comorbidity. There's recent evidence that women struggle in a given quit attempt, so male gender seems to also provide a slight advantage. Having fewer smokers in your social network, quitting within your first few days of making your quit attempt are also predictors of abstinence. Perhaps the most important one is the use of treatment, so we really want to encourage people to use treatment to greatly increase their chances of having a successful quit attempt. Why is it so hard to quit this drug? Patients often report that their experience is that it's harder to quit smoking than even heroin or other drugs that they may have been addicted to in the past. There isn't really scientific evidence of that except to say that there may be reasons why people perceive it to be that way. Certainly smoking a drug is a highly addicting way to put drug into your body. It's highly reinforcing because of the drug delivery that we talked about. It could be that smoking is ubiquitous and so harder to remove smoking from your life if it's available in your environment. Certainly treatment options are limited. There's only a few medications that are available. Most people receive limited, brief, or even no counseling support to help them to quit, and there aren't levels of care, so it's not really able to check yourself into detox or rehab or even any kind of intensive treatment program to help you to quit smoking, even if you've been unsuccessful a hundred times prior to that. In addition to having few treatment options, we can't even seem to get people to use the ones we have, so utilization tends to be poor. People don't use counseling or perhaps they don't use medications properly. They may provide them to themselves in too low of a dose or for not enough time, and that can, of course, contribute to worse outcomes. In thinking about what we can all do to better address tobacco, everyone can do this strategy called two A's and an R, which would be a brief intervention. It stands for ask, advise, and refer, so even if you're not a specialty provider or you're not in a job role where you can provide direct cessation support, everyone can ask about tobacco, document tobacco use at different interactions, give people brief advice or ask them how they feel about quitting, and then refer them to a place where they can receive more information and more services. This is a primary care model, but it's certainly useful in a variety of healthcare settings and is the absolute minimum that we all can do as healthcare professionals. But hopefully we can do more than that, especially in the behavioral health setting where people really are experts in counseling and have a variety of skills that make them well-suited to treat tobacco. In terms of messaging, there's a lot of new information about engagement strategies. Why not encourage patients to quit for a day or even for a few hours? They could save some money. They could try some nicotine replacement and report back to you what their experience is like. They might feel better. They might be able to try a new skill. They could try other coping. Lots of reasons why we could frame it as something that seems worth trying for people. It's interesting that for alcohol treatment, for example, you're allowed to quit one day at a time, but with tobacco, it's always framed that you have to quit forever. For many people, that can feel insurmountable, so anytime we can break it down this way, have people think about it in a one-day-at-a-time kind of frame, it can be more useful. Similarly to this idea, even assessment can be a therapeutic activity, can help with giving people some feedback and engagement around their tobacco use. We can think about tobacco as a co-occurring disorder where we take a long-term approach and we integrate it into our other behavioral health treatment. We can really frame these interventions as treatment. People who know me know I'm not a big fan of the word cessation. We don't usually frame other types of behavioral health treatments in terms of an all-or-none phenomenon. We don't usually have a whole spectrum of treatment options from harm reduction to more aggressive treatments. I think people would find this much more realistic for them if they felt that there were a range of options as opposed to this finality of having to quit forever, which can just be overwhelming for people. In terms of evidence-based treatments, there's lots of evidence that counseling and medication are both effective, and I'll say more about that. In terms of co-occurring disorder treatment, this is the model for doing co-occurring, which we know is highly effective in terms of helping people who have both mental health and addiction problems. We know that treatment works best when it's integrated and comprehensive and matched to people's motivational level. These kinds of treatments take a long-term perspective because often people may not have an immediate goal for themselves of abstinence, but we work towards abstinence as a long-term goal. We can work with people even who don't want to achieve abstinence by doing a continuous assessment, motivational interventions, and it's interesting that some of the most highly effective strategies for co-occurring disorders treatment include the use of medications, as well as the inclusion of the support services such as case management and housing. That seems to me to fit quite well in thinking about creating a plan to incorporate tobacco treatment into care. The telephone quitline is an additional resource that we can use. It's typically free and available in all states. The way the quitline is structured is that it provides an assessment of somebody's tobacco use and a series of follow-up calls arranged around the time that someone may want to try to quit smoking. The person on the phone is a tobacco specialist. They're often available, these services, in many languages. They may provide free nicotine replacement as part of the enrollment. They're good for a whole range of issues, like you don't need transportation, you don't need a babysitter, and they are associated with success in helping people to quit. Some of the best research of modified quit lines is coming out of Australia by Amanda Baker and colleagues, where they're really doing a modified quit line approach, where peers provide information and help facilitate a linkage to the quit line. That seems to be an important step, proactively referring people rather than waiting for them to call. They provide this quit line service with combination NRT, so a pretty aggressive dose of medication to support the telephone counseling. The person on every call is speaking to the same counselor, which is helpful for issues of trust and rapport, and the quit line services are pretty well integrated in terms of providing feedback back to the primary mental health team, so we can adapt quit line services to help them be even more effective for these populations. We know that among behavioral health treatment professionals, there's a lack of knowledge in terms of knowledge of the evidence-based treatments. Several studies have shown this. We have also demonstrated a lack of knowledge among psychiatry residents who typically don't learn about tobacco use disorder during residency. We did a project where we developed three online webinars and sent them out across the country for residents to view. This evaluation showed that they had significant increase in learning in terms of what they learned from the webinars. They also were highly recommended in terms of feeling that it enhanced their professional experience, but perhaps most importantly, we were able to show that as a result of watching these webinars and providing education that these psychiatry residents went on to provide more specific tobacco treatment in a variety of areas, so that's really a key outcome in terms of changing behavior, and we know that education is really an important way to do that. In terms of what's new for different medications, I mean, there's tremendous evidence that the medication treatments are effective and cost-effective for helping people to stop using tobacco. They increase the chances of a successful quit attempt by two to three times. The main way that they work is to help reduce or eliminate tobacco withdrawal symptoms, but they have additional benefits as well. They lessen or delay the weight gain associated with quitting smoking, and they help to block the pleasure that comes from smoking, so-called reinforcing effects. Although I'm going to talk mainly about medication now for the rest of the webinar, it goes without saying that people should really ideally receive access both to counseling and medication, which gives them the greatest chances for success. We have a lot of experience with these seven FDA-approved medications, actually soon to be eight. Several types of nicotine replacement and bupropion are shown to be effective in a variety of studies and at least double the chances that someone will successfully quit smoking compared to if they received a placebo. Varenicline, interestingly, is associated with three times higher rates of success in quitting smoking, so has demonstrated superiority in terms of its overall efficacy, and I'll show you some of that data. Some key aspects of nicotine replacement therapy that although the patch, the gum, the lozenge, and now the newly FDA-approved oral spray are over-the-counter medications. They may be covered in your state if you write a prescription by the state's Medicaid plan. That's really important when we think about the people that need access to these treatments the most are low-income populations, and so if people can access them for free or low cost through their Medicaid, that's actually a huge advantage, and you can look up what your state covers on this website that is maintained every year by the Lung Association. There's two prescription forms of nicotine replacement as well, the inhaler and nasal spray, that tend to get used less, and all of these medications are referred to as NRT or nicotine replacement therapy. Some of the themes of nicotine medication. Typically, people don't use them in a high enough dose, so they have to be encouraged to use a high enough dose and for a long enough time period to get the best effect. We have a lot of evidence now that when people use two nicotine medications together, it's superior to one, so they're safe when combined with each other. Nicotine has no drug-drug interactions, and remember there's almost no one who is not a candidate for nicotine replacement therapy because when we provide a smoker with nicotine, we're not even really introducing a new substance. This is something that they've already been taking for decades, just in a cleaner form and without the toxic effects of smoke. That's why these medications are safe enough to be over-the-counter. And again, there's abundant evidence in the cardiology literature that these medications do not increase risk for cardiovascular events, so these are safe medications. They're well-tolerated. Neither nicotine nor bupropion nor varenicline are associated with increased risk of cardiovascular problems. What really causes cardiovascular disease is the effect of smoking, and so we, overall, these medications are considered to have low risk of harm, and the benefits outweigh the low risk of serious adverse effects, and we should be using them much more aggressively. I'm going to skip some of this information, except if people have questions. The patch is fairly straightforward. We recommend that people start with the 21 milligram full-strength dose. You can experience some mild side effects from it. It's generally better if people wear it at night when they sleep. It's fairly straightforward. One of the limitations of the patch is that it may not be as effective for the acute experience of craving, and for that reason, people may want to supplement their patch with a short-acting form of nicotine, such as the gum, the lozenge, and now the newly approved oral spray, which will be hitting the stores any day now. These short-acting nicotine formulations typically, in a dose, deliver the equivalent of a half to a single cigarette, so don't be worried that people are going to overdose. These are generally low-delivery nicotine products. They generally go in through the mouth, which is not a highly efficient way to deliver nicotine. Therefore, you have to use a lot of doses of them for them to have their best effect. When you use nicotine in the mouth through these products, you have to generally educate people not to use them at the same time as coffee or soda or other beverages which are acidic and interfere with the absorption of nicotine. The oral nicotine spray was FDA approved in September, although it's been available around the world for some time. It's a spray of nicotine that goes directly into the mouth, and some of the dosing information is included on this slide. There's no evidence of product abuse. Again, this medication has been used in Canada, Europe, and throughout the world for some time. It seems to have similar efficacy to other forms of nicotine replacement. One consideration may be it does contain really trace amounts of alcohol, not significant, but still may be an issue of concern for some people in alcohol recovery who may want to avoid use of this product because of that. When people experience hiccups and GI symptoms, it's typically because they're swallowing too much of the nicotine, but that is slightly more common with this formulation. As I mentioned, there is also prescription nicotine, the nasal spray, and the oral inhaler, which tend to be used less because they are more expensive, but are additional options for people. When people use nicotine at the same time that they're continuing to smoke, we now have a lot of evidence that that seems to have a relatively low risk to people. It seems to be a relatively safe practice. It may reduce some of the enjoyment from smoking and help people over time to smoke less. Studies of unmotivated smokers receiving nicotine show that about 7% quit. So again, we do want to be encouraging people to use this, not to be overly alarmed if they're having lapses of smoking, really helping them to continue to use the product and try to quit as much as possible. Bupropion, you're probably familiar with as it's a commonly used antidepressant medication. It works with similar efficacy to nicotine replacement. Its exact mechanism is not clear, but may have effect at the nicotine receptor as an antagonist. Generally, people start this about two weeks before the time that they're going to try to quit smoking. It works independent of depression, so it can be a great choice for a depressed smoker, but in fact helps people to quit smoking, even if they have no history of depression. And out of all the medications, may carry the greatest benefit in terms of reduced risk for weight gain when people quit smoking. As I mentioned, there's a lot of evidence now that giving people what's called combination NRT, the combination of a long-acting patch and a short-acting nicotine replacement seems to provide better outcomes compared to single-dose nicotine replacement. It's giving, first of all, a higher dose than one might be able to achieve from a single product, but perhaps is most helpful in that you can supplement the patch with immediate craving relief. So, it's going to provide better coverage, hopefully reduce the risk for withdrawal symptoms, but using one of these immediate acting nicotine replacement products can provide in the moment craving relief within five minutes. That can be really helpful and act almost as a rescue medication. The last medication that I'll briefly talk about is varenicline or Chantix, which has a different mechanism of action. It's actually a partial agonist at nicotine receptors in the brain, the alpha-4-beta-2-nicotinic receptor. That gives it a variety of actions. By binding at that receptor, it partially stimulates the reward pathway. It's not addictive, but provides some tone in the pathways, which may be helpful in preventing withdrawal. It also, by blocking the receptor, blocks nicotine's ability to cause pleasure. So, when people are smoking cigarettes and taking this medication, they don't experience as much reward from that, and that can also provide benefit. The most common side effects seen with varenicline include nausea, insomnia, abnormal dreams. It should be dosed twice a day with food to reduce nausea and has a titration over the first one to two weeks. Because it's excreted by the kidney into the urine, there are no clinically significant interactions in the liver with other medications. Its efficacy has really been demonstrated in a variety of studies, including this large clinical trial referred to as the EGLE study, which was a head-to-head comparative study between varenicline, bupropion, and nicotine replacement in a triple-dummy design. This study intentionally included people with behavioral health conditions and was really designed to evaluate the neuropsychiatric safety of varenicline. Results showed that people who used varenicline to quit smoking were really the most successful in the trial. Almost 40 percent quit with varenicline in the non-psychiatric cohort. That was significantly better than groups who received either bupropion or patch, where we see consistently quit rates around 25 percent, and all of those are significantly better than receiving a placebo. Again, this study was set up to have approximately half the subjects had a psychiatric illness. These were stable outpatients with a variety of conditions, and you see that the same trend is even true in the psychiatric cohort, where the most people are able to quit smoking with the varenicline treatment, although you see overall that the success rates on this attempt are lower compared with people without psychiatric illness. So again, the message is that people with behavioral health conditions can quit smoking, and the same treatments seem to work, although the overall success on a given attempt seems to be lower. Again, this study was mainly designed to evaluate the safety of varenicline in terms of its risk for neuropsychiatric side effects. Many things were evaluated and tracked, and I would encourage you to look up the papers if you're interested in the details of this, but essentially there was no difference between the treatment groups in terms of risk for neuropsychiatric side effects. This is looking at moderate and severe. So this was enough for the FDA to remove the black box warning about the risk for neuropsychiatric side effects, although real side effects that people might experience from varenicline, as I mentioned, include nausea, insomnia, and abnormal dreams. So given the safety of this, the field has started to shift now in terms of thinking about a hierarchy or treatment algorithm. We have a lot of evidence now that both varenicline as well as combination NRT are really highly effective strategies, much more effective than other forms of monotherapy, and we should be considering these as first-line treatments. In this article published by Scott Leischow in JAMA in 2019, he even went as far as to say, you know, given that varenicline had no more risk for side effects than nicotine patch and bupropion, we should even think about varenicline as an over-the-counter product, which would increase access significantly. In thinking about who to use medications for, the question comes up, well, my patients aren't saying that they want to quit smoking. Should we use medication for them? And I think that we can think about using medications for those kinds of populations. Over time, it may help people to lower their level of addiction to tobacco, which can increase their chances of successfully quitting over time. If they are working to reduce their smoking, it may help minimize the withdrawal associated with that. You can think about that as a harm reduction strategy. But again, these kinds of slow reductions with medications are associated with higher odds ratio for future quitting. So, these reduced-to-quit paradigms are becoming more common. Can we use these medications long-term? How long should someone be on tobacco medications? And generally, the longer we do the studies, the more we see the benefit of a longer-term use. Typically, we think about a treatment episode of about six months. It can be a struggle to encourage people to use the medications for that long, but they seem to be more effective when used for a period of six months compared with shorter outcomes in terms of greater chance of preventing relapse. It's important to remember that tobacco smoke itself causes significant medication interactions in the human body. The tars in tobacco smoke induce the liver cytochrome P450 system. They have a specific effect on the 1A2 isoenzyme. This is not a good effect because it tends to be psychiatric medications that are affected mainly by the 1A2 enzyme. This means that smoking increases the metabolism of these medications, which may reduce the blood level and the overall efficacy of the medication. Over time, smokers tend to be on higher doses than of these medications and could be at risk, in fact, for toxicity of these medications during a quit attempt, where now the drug levels may rise rapidly. Out of all the medications affected by 1A2 in smoking, clozapine is the most relevant in terms of risk for harm because a rapid rise in your clozapine level associated with quitting smoking can produce a toxicity syndrome and cause people to experience seizures. Keep in mind, this effect of smoking is not from nicotine. It's from the other tar in the smoke. Nicotine itself doesn't have any important clinically significant interactions and is metabolized by a different enzyme. These are some of the most clinically significant medications that are impacted by 1A2 in smoking. You see a range of antipsychotic and antidepressant medications. Interestingly, caffeine is also on this list and helps us understand why smokers tend to be heavier users of caffeine, and we want to think about the context also of caffeine toxicity and the risk for that when people are quitting smoking and perhaps counsel people to reduce their caffeine. Just as a review, nicotine doesn't have clinically significant interactions in the liver, varenicline doesn't either because it's excreted by the kidney. Out of all the treatments I've talked about today, bupropion has the risk for most interactions. I wanted to say something about alternatives, so-called lower risk products, e-cigarettes, also referred to as electronic nicotine delivery systems. Because these are not burning products, so they may heat the nicotine, but typically there's no burning that's happening. There are no products of combustion. There's no carbon monoxide. You can think about these products potentially as safer than a cigarette, but that doesn't necessarily say that they're safe because they may carry their own risks. In this country, they're not currently regulated in terms of sales or advertising. There's really wide variety. It's hard to generalize because there's so many different products, and this is a rapidly changing market. Again, there's no testing or regulation currently in the U.S., and there's a lot of co-use with THC cannabis in terms of emerging vaping culture. These are really something we should be vigilant about. The vape that comes out of e-cigarettes, if you analyze it, can contain a variety of chemicals. Typically, it also contains nicotine. It may contain flavors, flavoring agents. The level of chemicals found in vape are typically much lower than you would find in a burning cigarette, so although you may have some of the same metals and carcinogens and toxins, it's typically overall in a reduced rate compared to cigarette smoke. Of course, there are concerns with the use of these products, particularly because they lack any testing or regulation. We all now know about the emergence of EVALI or a vaping-associated lung injury, which happened in the last two years where there were actually deaths reported in 27 states associated with e-cigarette and vaping use. Although 86% of these involved people who were vaping also THC, there were some cases where people were vaping nicotine alone. The prototypical vaping patient is male, less than 35 years old, and the exact etiology is not known but highly suspected to be related to vitamin E acetate contaminant, which was in the products and recovered from lavage and other agents, and this was used as a thickening agent and shown to be quite toxic to lung tissue. I'm just going to conclude by saying that there's a tremendous amount of resources which are available for working on tobacco. I'm part of a project funded by New York City through Columbia Center for Practice Innovation, where we are providing training and technical support in New York, but also have a website with free resources that anyone can use and access, so just wanted to bring that to your attention in terms of an additional resource. So just to conclude, this was a very rapid review of a lot of different subjects. The main themes are it's the smoke that kills. It's very different when we talk about tobacco smoke. Nicotine is only one component of thousands. We should really think about tobacco as a co-occurring disorder, emphasize engagement strategies, helping people to work on it even as a long-term issue. We should think about medications for anyone with at least moderate levels of nicotine dependence to find a smoking in the first 30 minutes of waking up in the morning, and we know now that people achieve better outcomes when we provide them with education to use the medication effectively, whether that's at an effective dose or for a long enough period of time. Combinations of nicotine replacement or varenicline can be considered first line because we know that these are superior to other treatments, and we can think about longer durations of treatment for relapse prevention. So I will stop, and I believe we have some time for questions.
Video Summary
In this video, Dr. Jill Williams discusses updates in treating tobacco use disorder. Dr. Williams emphasizes that despite smoking rates in the United States being at an all-time low, smoking is more prevalent among populations with mental illness or substance use disorders. Smoking is still the number one cause of preventable death in the US and contributes to various health issues. Dr. Williams explains the toxic components of cigarette smoke, including nicotine and carcinogens, and their impact on the body. She discusses the negative consequences of smoking, such as financial hardships, employment difficulties, and increased risk of mental health problems and substance relapse. Dr. Williams also highlights the importance of addressing smoking as a social justice issue. <br /><br />She discusses various strategies and interventions for addressing tobacco use, including public health initiatives, support for treatment and cessation efforts, and increasing access to pharmacotherapy. Dr. Williams provides an overview of evidence-based treatments and medications for tobacco use disorder, including nicotine replacement therapy (patch, gum, lozenge, and spray), bupropion, and varenicline. She emphasizes the importance of integrating tobacco treatment into behavioral health care and using a comprehensive approach that includes counseling and medication. Dr. Williams also touches on alternative products like e-cigarettes and their potential risks and benefits.<br /><br />Overall, this video provides a comprehensive overview of tobacco use disorder, its impact, and evidence-based treatment approaches.
Keywords
Dr. Jill Williams
tobacco use disorder
smoking rates
mental illness
substance use disorders
nicotine replacement therapy
e-cigarettes
social justice issue
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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