So lots of people saying that they really enjoyed your talk, it was quite helpful. So we have a psychiatrist who wrote in and asked, is the smoke in a marijuana cigarette less dangerous than smoke in a tobacco cigarette? So that's a great question. And we say that cigarette smoke is estimated to have thousands of chemicals if you sort of distilled it or studied it in a laboratory setting. It is similar to cannabis, although estimates are in the hundreds rather than the thousands. So cannabis smoke might contain thousands of different chemicals, not only the cannabinoids, but a variety of other substances. Again, when you smoke it or burn it, you're still going to have carbon monoxide and some of the same products of combustion. So in some ways, not exactly the same, but maybe some similarities in terms of risk and certainly exposure of carbon monoxide, which is one of the most dangerous products of combustion associated with smoking. Terrific. Another individual asked, what about varenicline plus NRT together? So that's a great question. We've talked today about how combinations may be more effective than monotherapy. What's interesting though about varenicline and nicotine together, there's kind of conflicting evidence as to whether or not that's a better treatment strategy than varenicline alone. When you think about the way varenicline works is it's targeting the nicotine receptor in the brain. So the idea conceptually, if you think about it, is that by adding nicotine, you may not be providing additional benefit if the receptors are already saturated with varenicline. The nicotine would essentially have no place to go. There have been some groups investigating the potential usefulness of some additional NRT, maybe in the first week while you're just titrating up varenicline in various scenarios like that or for intense craving. But I would say that's considered experimental at this point and that there are some studies that showed people did better when they received varenicline and nicotine at the same time. And then there were just as many studies that showed there was really no benefit from that combination strategy. So that's generally not one that I recommend. Let me finally I'll just say that the other risk of using varenicline and nicotine replacement together is that it seems to increase the risk for nausea and some of the other side effects. Around varenicline, there was a question came in and I think we covered this, but I'm not sure. It said, has the black box warning from varenicline been removed and what was the reason? Are you there? Jill? I'm going to switch to this so you can hear me. Is that better? Yeah, that's great. Sorry about that. That's okay. Yeah. It's in response to the EGLES trial, which again, 8,000 patients, big, big multi-site clinical trial showed no increased risk for neuropsychiatric side effects from varenicline compared with people who got either bupropion or nicotine patch or even those that got placebo. The rates for neuropsychiatric side effects were essentially the same across those different groups. So that did in both Europe and the US have regulatory implications. The FDA did remove the black box warning within about six months of the release of that study and in response to that really overwhelming evidence that varenicline did not seem to increase the risk for suicide and other serious neuropsychiatric events. Wonderful. Regarding smokeless tobacco, are the same agents used for stopping cigarette smoking effective for chewing tobacco as well? So there's always fewer studies about that, which makes it a little bit hard to interpret. There isn't as much body of evidence about the use of the medications. But of course, we think at a basic level, nicotine addiction is nicotine addiction. And so conceptually, it would be fine to use any of these treatments to support somebody who's also struggling to stop their use of chewing tobacco. You could think about this the same way even with e-cigarettes. We don't have a tremendous evidence base at this point. But it's common sense that if people have addiction to nicotine, that they might benefit from these treatments to help them to quit. Wonderful. Which products are covered under Medicaid? So that varies from state to state. You really would have to look up the formulary for your own state. However, I would say in the last 10 years, access has greatly improved. Many states now allow for these medicines to be free through Medicaid. So typically, the patch, the gum, the lozenge, bupropion, and varenicline could potentially all be free through your state Medicaid program. The prescription nicotine products could also potentially be free through Medicaid, although that's going to be more variable. And again, you need to look exactly at what's covered in your state because sometimes there are limits on how long people can receive the medication. Although, again, that has improved significantly in recent years. Do you recommend closer monitoring of psychiatric meds during a quit attempt? I do. You know, for many of these medications, we talked about the important interactions, and of course, that's a reason why you would want the behavioral health team and the psychiatrist to be involved in providing the tobacco treatment, ideally, because something like changes in symptoms and changes in these medication blood levels can really impact the outcome and would be important for the team to be monitoring. You know, clozapine, it's maybe easier because you could track a blood level for that. That's not really available for most of the other medications. But I think to be checking in with people and to monitor them to make sure that they're not having more sedation or confusion or potentially any other side effects in the context of quitting smoking would be really important to do. Terrific. And I know you talked a lot about using the words treatment rather than cessation and one day at a time rather than quitting for forever, but we had someone write in and say, do you have other specific suggestions about how to try to move clients in the direction of quitting? Well, there's been a lot of work in even brief motivational interventions. So nowadays, most people are trained in how to use motivational language and at least the style of motivational interviewing, even if you're not doing it in the strictest sense. And so I think that those approaches certainly would be very helpful for working with people about their tobacco and should be used. So I think really meeting people where they're at, rolling with the resistance, trying to set some short-term goals, encouraging people to try treatment. And I think there's a whole range of things that you could think about consistent with motivational approaches. Wonderful. I have a question that I'm actually going to answer, but I'm going to read it out loud because I think it's important. So someone wrote in, are the 45-minute webinars that your team has, can they be distributed to resident physicians to use as part of residency programs? And I think this speaks a lot to your talk today, which is one that we really want to get out to the masses as very practical. And so my answer to that is absolutely yes. Within our website, smiadvisor.org, there's a clinician tab. You click that, and then within that, you can see our on-demand webinars. This one will be available within just a couple days. And you can have, you can assign residents or fellows or groups that are new to your rotating through your clinic, assign them one of these webinars, and then they can watch it, they can sign up, they can watch it, and then you could, for example, discuss it the next week as a group. It could be sort of like your journal club. There's a lot of ways to use this, and we would love for you to use these resources in whatever way helps to get the word out to improve evidence-based care for the individuals with serious mental illness. So here's another question that came in. When considering tobacco industry lawsuits over the years, what happens with funding received from those lawsuits? So that's a great question, and it's certainly relevant to today's discussion with Purdue and other opioid settlements emerging. Unfortunately, at the time of the tobacco settlements, which now is about 25 years ago, the states really were not mindful, and very few actually used that money to help smokers. The payments that were made to the states through the master settlement were just general funds for the states, and they were allowed to do whatever they wanted with that money, and they used it for a variety of things. And so unfortunately, a lot of that money disappeared and was not as helpful in supporting programming or really being used to help tobacco users, and that's a huge loss. We learned from that historically, and I think people are trying to be mindful of that as we sort of grapple with these newer opioid settlements and try to be more specific maybe and detailing the way that that money could potentially help the most people and have the greatest benefit. When you think about the behavioral support that you recommend that goes along with the medications, what should be in the content and at what length should that exist? So a variety of different approaches work for helping people, and what's interesting is that the skill set that you need to do to help people to stop using tobacco would be the kind of skill set that most people who work in behavioral health would already have. So relapse prevention and social skills training and sort of being able to recognize your patterns of drug use, avoid high-risk situations and triggers, be able to do stress management, relaxation, all of those things can be helpful as components, which make the counseling quite similar to lots of other types of behavioral therapies that we deliver. So I would say a variety of things work, and it should be quite easy for people working in behavioral health to be able to provide these kinds of counseling therapies. Terrific. Well, that concludes our questions.

smoking cessation

Medicaid coverage

psychiatric medications

educational webinars

evidence-based care