 So Dr. Janaki Deepak, she was one of my close friends and colleagues during residency at Harvard Hospital. She's agreed to do Grand Rounds this morning, and we'll be talking about smoking, liberation, myths and facts. So a little bit about Dr. Deepak, she's currently a pulmonary and critical care physician at the University of Maryland. She's an associate professor in the Department of Medicine and assistant program director in the pulmonary and critical care fellowship department, also director of the lung cancer screening and tobacco health and treatment program. So she started a journey in medicine at the Sheth GS Medical College, University of Mumbai, India, and she completed a residency in diagnostic radiology. She then completed her internal medicine residency at Harvard Hospital, where I was a co-resident along with her and chief resident. And then she went on to complete a fellowship at the pulmonary critical care medicine department at the University of Maryland Medical Center. Dr. Deepak also has been heavily involved in the local Maryland ACP chapter, where she's been running doctor's dilemma as well as students' doctor's dilemma competition. And she just recently was chosen to win the Herbert S. Waxman Award for Outstanding Medical Student Educator for the National ACP chapter. So today, welcome, Dr. Deepak, and thank you for agreeing to doing Grand Rounds this morning. Thank you so much, Dr. Kunkun and Dr. Thomas, for inviting me to speak here. And Dr. Kunkun, everything I learned about teaching, I learned at your footsteps because Dr. Kunkun was definitely my resident, but also my mentor and how well to teach. Though I never adopted his teaching style, I've been trying, but he's just such a sweet teacher, and I am the fiery teacher on the other hand. So thank you so much for your kind introduction. I have no conflicts of interest, except I am passionate about it. So there's going to be I'm going to talk to you a little bit about the historical aspects and then focus a lot on the effect of nicotine on the brain, which I think that we just don't do enough. And that's why we get misled on how we deal with patients with tobacco use disorder. A little bit, just a little bit on the electronic nicotine device systems. I know you all have had a Grand Rounds on that, so I'm not going to wax lyrical about it. A bit about what is motivational interviewing and counseling, whether that's enough. And then treatment, the actual treatment, and then some of the medication that's a little bit about COVID-19 and smoking and also vaping. And I have some unpublished data from our clinic and some take home points. Okay, so let's go into a case. And I want you all to keep this case scenario in mind as we are going through this entire presentation. So this is a 65 year old man, new diagnosis of scrimacial cancer, stage two B, which means that he has lymph nodes, which usually are N1 lymph nodes. And the treatment for stage two B is usually surgery with chemotherapy afterwards. He has tobacco use disorder with ongoing use. He has about 40 packets of smoking. He presents to clinic for optimization of his primary status prior to surgery. His FEV1 is 34% predicted. And FEV1, FEC ratio is 40. So for the trainees out there, the fact that the FEV1, FEC ratio is 40, it means that we have obstruction. The FEV1 is 34%, which means we have severe obstruction. And then the DLCO being 35% usually means severe defect in gas transfer. In addition to the management of his smoking related lung disease, what are the other interventions that's going to be helpful at this time? Discussing with the patient about setting up quit date for stopping smoking. And I want you all to all truly write down your things in chat so that it's not about commitment or getting something wrong. It's about how you feel about it. And hopefully I can change your mind about it. Motivational interviewing and referral to tobacco counseling. Offering the patient nicotine patch or varnicline, which is called shantix. And there is epivarnicline, which is again generic form of varnicline from Canada. And discuss with the patient about tobacco addiction and prescribed controller, which could be any of those patch, varnicline or bupropryon and a reliever medication. So I'll give you all like a couple of seconds to kind of commit to something on chat. And then we'll move ahead. So I'm hoping to see some chat messages pop up. One person has braved it, come on. Awesome. Awesome. Let's get to 10. Come on, we can do this. It's early morning. We got a coffee. We can do this. Yeah, in case people didn't tell you, I'm also very energetic. So if I'm over energetic, I apologize. Guard at six, seven. Let's do it. Let's do it. We have not even reached, we've reached about 10% now. Yeah. More than 10%. Let's get to 10. And then we move. No. Okay. That's it. Seven. Okay. So hopefully people will take their time and do it. So let's go to the history. It's fascinating how actually we are in today's situation. So how did it start? There were traces of nicotine discovered in Mayan flask dating more than 1000 years BC. Nicotine tobacco, as we know it now, actually came from the Native Americans or the American Indians and they used it, as you can see, they're waxing lyrical about how good of medicine it is. And this is in 1590. So what happened is when Columbus discovered America, he also took these tobacco leaves and spread it everywhere in Europe. Europe never had it before that. And then that's how it actually went to Europe. So it's a very interesting journey. If you see how tobacco went from the Americas to everywhere else, and though it was existing in other places, like there is enough of Indian mythology, which talks about forms of tobacco, and it is definitely there in South American literature. But that's how it went to Europe. And then here is James the first who basically had his counterplastic tobacco where he said that it's horrible. I mean, he was clearly racist. I'm sorry. But in some things that he said, it loads into the eye, harmful to the nose, harmful to the brain, dangerous to the lungs. He was absolutely correct. Absolutely correct. This was way back when and he was absolutely correct. You can see it 1604. But we have still not realized it, unfortunately. So tobacco is the name for the plants of the nicotine family or the nightshade family. It's actually a pesticide in case you all don't know. The English word tobacco came from the Spanish and Portuguese word tabaco. It's also used. It's manufactured from tobacco leaves, cigars, cigarettes, e-cigarettes, vaping devices, hookahs now fight chewing tobacco. And in 1560, Jean Nicotte, the French ambassador to Portugal, bought it to England and France from Columbus. And as you can see, it was Nicotte and a lot of the nicotine comes from there too. So this is our public enemy number one, Philip Morris International, who has this beautiful diagram on how it gets blended to the best product in the world. Political influences a lot of it. So let's think about what we've done. So in 1612, Englishman and husband of Pocahontas, all of you who have kids have hopefully seen Pocahontas, planted the West Indian tobacco in Jamestown. And in 1617, when there was a, you know, the new governor came there, he said, everything else is bad, but the signs of success is everywhere there's tobacco. And then to the colonists, it became a legal currency in Maryland and Virginia. So we are very much culprits in this. And this led to the growth of seven to 35% of Chesapeake regions in slave populations. So there is a big backdrop to this. And it's very sad. Reports of cancer has been there for quite some time. I just love all these old diagrams. It's beautiful to see these journals. And then they talked about lung cancer, or more Gagney talk, more Gagney of more Gagney, Sonia talked about lung cancer quite some time ago. Okay, so what did we do? We did a lot of reviews, we said it cures asthma. Okay, we said, so doctors smoke cigarettes as scientific effects, and it's best for you. And dentists said it's good for you. And everyone said it's good for you. And then we tell now our patients that it's not good for you. So no wonder they don't want to believe us. Oh my God, I forgot that I've done this, sorry. And then we did not spare our soldiers, we gave it to them and we said, what do you need? General John Foshing said, what you need to win the war is a cigarette in every soldier's hand. And there it was, cigarette in every soldier's hand. And then the bald Roman, who all of you know about, but guess what, he never ever smoked, he died, I think two years ago, he was 89 years old, he never smoked. So there have been enough things, thankfully, in 1964, there was a surgeon general report said that this is really bad. In 2019, there was more. And this time we had talking about e-cigarette use for the first time. All of you know about this, I'm not going to belabor the point, it does cause a lot of bad damage. It's known thing. So let's talk a little bit about addiction criteria. Addiction primary criteria is highly controlled compulsive use, psychoactive effects and drug reinforced behavior. So now let's deal with nicotine addiction. So nicotine dependence is a chronic, relaxing disorder. It has cycles of compulsive cigarette smoking. It is followed by periods of abstinence resulting in withdrawal. So it is an addiction. It's also chronic health disorder, as I'm hoping to convince you. So why do people smoke? So I have this picture of this man who's on oxygen. He blew himself up, he blew his house up. Why do they do it? Like, you know, why they know it's bad for them? It's not like they don't know it. So the magic happens in the brain. The magic happens in the ventral tegmental area. It happens in the nucleus accumbens. And it's all because of this nicotine. So it hijacks the survival instinct. So what do I mean by hijacking the survival instincts? I mean that, my God, that was like going on and on. So it, the unique thing about nicotine compared to any other product of addiction is that not only it acts on the ventral tegmental area, which is responsible for the safety and threat cues from the environment. So we are, we know as a child, we teach our children, don't go and put your hand on fire. Don't cross the road without looking both sides. If there is a car coming, you step back. These are things we teach people and it becomes instinctive in us. That cues are going to the ventral tegmental area. But guess what is there? What are the receptors on the ventral tegmental area? It's nicotinic receptors. So nicotine acts as an external ligand to these receptors. Notice I use the word nicotine and I'm not using the word, I'm not using the word cigarettes alone. So nicotine from combustible tobacco products, from combustible tobacco products goes to the brain in six seconds, goes to this ventral tegmental area, goes and attaches itself to those nicotinic receptors and now acts as an external ligand for safety. It then promotes this feeling of safety in the brain. It helps expand the number of receptors and at the same time it desensitizes the receptors. So it's a very fascinating thing and it is the only, only product right now which does it. So that is why it creates the sensation of my God something is happening to me and this leads to the next problem which usually is the compulsion. So what happens in the compulsion is that now that it has acted as an external ligand and it tells the brain as long as you're seeing me, you are fine, you feel safe, any time that they try to stop smoking it creates something called as a negative prediction error and that negative prediction error is so strong that it creates a compulsion that people have to pick up the cigarette unconsciously and start smoking again. So this is why when you tell people set a quit date it's just so false because it is literally impossible for people to set a quit date and stick to it because of this effect on the brain. So what does it mean when I say that there is connections between environment and behavior? What I mean is that nicotine is very well known to actually be able to know where you smoke. So if you get up in the morning, switch on your coffee and smoke, it's going to give you that cue every morning like an Alexa and it will tell you, you know, it's time to do this, it's time to do that. Don't make anything you're comfortable with me knowing. Alexa, stop, see my Alexa is talking. So that's what nicotine does, right? It is very, very powerful and it kind of gives those cues every time. So it knows if you're going to the coffee shop in the morning drinking your coffee and smoking, it will give you that cue every time, which is why patients who smoke sometimes when they come to the hospital, they don't really want to smoke as much. They are not that they're not necessarily running outside and wanting to smoke all the time. Some patients do, but not all the time. And if you go to a different environment that urge to smoke is not there. So it is actually being studied in monkeys and this compulsion is very, very strong. And all this happens because of all the glutaminergic pathways, the dopaminergic pathways to the prefrontal cortex, which is in responsible for the executive function, the nucleus accumbens, the hippocampus, the ventral tegmental area, the amygdala, all these together are forming this. Remember nicotine addiction is the only addiction where the person is fully functional. You do not ever recognize that this person is, you do not look at a person who smokes and says they are an addict. They don't, they are fully functional. They have high IQs. They are able to do everything, but it is an addiction and it is a chronic disease. So the connection to emotion and stress again is related completely to the mesolympic dopaminergic system, which controls the whole emotion, motivation, memory. So the minute they get stressed out, they'll pick up a cigarette because it calms them down, calms them down. So the cigarette is a highly engineered nicotine delivery device system and actually so is the electronic nicotine device systems. So this treatise from William Dunn from Philips Morris clearly said that the nicotine, the puff of smoke is the vehicle of nicotine. It is dispensing nicotine and smoke beyond question is the most optimized vehicle of nicotine and the cigarette is the most optimized dispenser of smoke. So how did this happen? It happened when he tried to tell them that, hey, nicotine causes addiction and they said, so be it. If it makes them smoke more, this is the best thing in the world. So he discovered long time back and he wrote a book long time back about the fact that what we are doing and what we are delivering is nicotine. So what is there in a cigarette? I have the anatomy of the cigarette, so there is nicotine, there is menthol, targeting the black population, there are ventilated filters, there are sugars and aldehydes, which is why it doesn't taste as bitter as it should. There are organic salts, there are nitrogen amines and there is ammonia. Ammonia is tea because ammonia is responsible for converting nicotine to a highly alkaline form, which then goes easily through the alveolar capillary membrane and goes to the brain real quick. So this is more on the anatomy of the cigarette and you can also see it as many other products which it should not have. And then addiction, it's not just an addiction and that is the problem and how we deal with it. We never ask our patients with hypertension and diabetes that should we treat you or are you ready to quit hypertension or quit diabetes, that's not how we talk about it. We say, here are what you need to do to take care of your high blood pressure and diabetes, so that is how we need to start approaching smoking or nicotine use because it is a chronic disease. And why is it a chronic disease? This is why it's a chronic disease because smoking cues, stress, results in craving, you smoke, there's a nicotine spike, there are activated nicotine, acetylcholine receptors, but immediately they're also desensitized, then it creates an acute tolerance, then it creates reduced levels of dopamine, then it causes withdrawal symptoms, then it increases craving and then this goes on and on and on and as you can see these activated receptors also cause neural plasticity, they cause conditional learning, they release dopamine and the most fascinating part of this is if your parents smoke and if a child is exposed to parents who smoke, they release something called as Delta PhosB which is a nanoparticle which makes the neural pathways start in the brain as a child which then makes them much more prone to getting into nicotine addiction. In addition, all these pathways, neural pathways that are created by nicotine addiction do not go down, doesn't decrease, the number of receptors, none of them decrease even if you stop smoking and you know that 10 times increase in nicotine receptors happens usually within 10 days, so it's kind of scary what nicotine does and these are the long-term changes it does, no connections, density, increased sensitivity of the receptors, it desensitizes them and it increases the sensitivity in the sense that much more nicotine is required now to make them give the dopamine and it changes gene expression which is what is responsible for some people being able to quit more easily than the others. So cure or omits, quit date, come back when you're ready, today you're not ready to talk about it but come back, next time we'll talk about it. Nicotine replacement therapy that is a patch or gum or losange or inhaler or nasal spray cannot be used while smoking. Patients have control over their smoking habits, shaming helps that is we've made rightfully so, we've made every indoor space smoke free but have we definitely given them designated places or designated times to be able to go and try to smoke, I'm not saying promote smoking but if people have been smoking all their lives this is not going to be easy, so as much as we are trying to make sure that we do not get exposed to second hand smoke and we are saying that smoking is bad, we do need to take care of the subset of people and then the victimization and when I am saying victimization it's like how many of you have referred to a person with tobacco use disorder as a smoker? I'm sure quite a few of you have done that, I used to do that, I absolutely used to do that till I learned so much more about tobacco and I was ashamed of myself or a vapor, these are not terms we should use and that is why I use the term tobacco use disorder. So let's talk about vaping for a minute, so it's a use of an electronic device that vaporizes the liquid to be inhaled by the user, these are the types of vaping and again I know that you guys have had entire grand rounds on this, I'm not going to go la la la about it, as you all know it has a mock piece, a clear tank, a heating coil, the things about vaping is even if people tell you they are only having marijuana as a vaping use disorder that still contains nicotine, so the FDA actually did many many many many many tests of many products and they found that products would say no nicotine or it's only a marijuana only product still contains nicotine but the same FDA now has approved that product, used product to help people stop smoking even though the literature for it is very haywire and not at all consistent, it contains not only nicotine, it contains heavy metals, it contains carcinogens, the tank systems can increase environmental exposure and the sweet flavors contain diacetyl and acetyl propanol, so aldehydes which are bad for you, vegetable glycerin propylene glycol which forms aldehydes like acrylon and why is acrylon bad because it actually impairs chloride secretion and that is the cystic fibrosis like picture, the heating coils contain metal fumes which are bad for you, the vitamin E acetate and ketene as you know is bad for you and all these lead to acute lung injury, so the data is not only the vaping associated primary injury, there is other things like we are seeing more patients with reactive airway disease, we are definitely seeing more patients with obstructive lung disease even in a younger population I have both a 16 year old with air trapping already with the RV of 230% with vaping alone, so this is not bad, this is not good and there is enough data now that it does increase the risk of heart attacks too, now there is another new thing on the market during COVID because they can't keep quiet during COVID so they had to come up with something else, oh don't wait instead use us because we are better, we are real tobacco, we are naturally present in tobacco and we are not smoking, we are not ashing, it's just a heated product, so these are the new products in the market, please look at your children's backpacks, see if they have anything like this because these are the new, this is the new fancy for everybody, so the traditional way to approach any person with tobacco use disorder is you ask them about it, you advise them to quit, you assist their willingness to make a quit attempt, you arrange your follow-up and you assist in the quit attempt, awesome, it doesn't work, so I would tell you all to get this new approach that is create a cognitive awareness, tell people, make people understand the effectiveness of nicotine, what I usually tell them is the brain is like a dog, most of the dogs love bacon, I think all dogs, I'm not a dog owner, so correct me if I'm wrong, dogs love bacon, bacon is our cigarettes, okay, so the brain which is a dog loves bacon which is the cigarettes, now you want to get the dog on a healthy diet of broccoli, so what do you do, you cannot give the dog broccoli because it's going to spit it out and it's like I don't want this, so you're going to give it bacon covered broccoli, so you approach it not like I'm going to give you broccoli, that is I'm going to make you stop smoking today but I'm going to give you something so that your brain still thinks it's something, it's still seeing the nicotine and it feels happy, the other thing I tell my patients which has a big effect is I tell them nicotine is like somebody who's pretending to be your BFF, your best friend, they come and live with you but as they are living with you and enjoying your hospitality, they steal from you and they steal the entire house from you, so nicotine while it makes your brain feel supremely safe and awesomely stress-free, takes away everything of meaning from every organ in your body, so that's what I tell them and I try to make them understand, I spend quite some time talking about the biology of nicotine and the hijacking the survival instincts, correct their tendency to sabotage, take baby steps, anticipate escape, offer questions instead of answers and then everybody has a different style, so tend to their style and aggressively control their compulsion to smoke aggressively. Okay, I apologize for all these, I should have taken them out, I thought I'd taken it out but clearly I didn't, okay so they have this disordered motivation and compulsion that is ambivalence, they're hesitant, I desperately want to go with smoking but not today, not now, Thanksgiving is coming, let's do it after Thanksgiving, I'm just too stressed out with Thanksgiving, I've got to make the toki and everything, it's going to be terrible, so I don't want to do it now and then there is this two-headed llama and I love this cartoon that says, what fits your busy schedule better, exercising or being dead, right, but that doesn't work, right, so they're going to tell you, doc, I stopped smoking but then I wanted to test myself so I went and got myself one cigarette to see if I could still do it but then I ended up going and buying a pack of cigarettes, so they're going to do this to themselves, they're going to find escape, they're going to tell you multiple barriers and they always have a low-grade panic and they're going to sabotage themselves, they're going to do this again and again and again, the other thing you have to remember and I talk to people about it a lot is the Odysseus effect which is very classic with nicotine and for those of you who know Greek mythology, Odysseus was a person who thought he could do everything, he was his own person, he was told not to respond to the sirens call because he would be dead but he said I won't be dead because I'm going to be attached to the mast right there and nothing is going to happen to me but all of you who have read Greek mythology which is not me, I read the Odysseus effect but that said no, that bad things came to Odysseus, so that is what nicotine does, it makes you do rash things which you know are bad for you so then it's very strong in them so you have to talk to your patients about it you have to motivate them more than disincentivising them and that is the only way to go these are the rules of the motivational interviewing, don't tell them what to do, understand what is motivating them, listen with empathy, empower them but this by itself is not enough, you need to also do some aggressive treatment so cigarettes per day is not and packs per day are not the way of going about the dose of smoke because the nicotine yield of the cigarette, number of puffs, frequency of puffs, volume of puffs, puff depth, duration of hold all play an effect, each cigarette actually can deliver anywhere from one to about 14 milligrams of nicotine so that's a lot of nicotine, there is a stepwise approach for tobacco dependence severity and usually if you have two or more medical conditions and or one psychiatric condition right then and you have a high phagostomic nicotine dependence scale then you will fall in severe or very severe disease in all the days that I have been doing this I have yet to see someone who's healthy medically and healthy psychiatrically and not had anything else what I'm trying to say is nearly everyone who comes through my door is either severe or very severe tobacco dependence there is a stepwise approach so not just asthma has a stepwise approach to doing it tobacco use disorder also has a stepwise approach to doing it so when you're severe or very severe you need to use controller and reliever medications sometimes you need to use multiple controllers so let's talk about the medications so what are our controller medications we have nicotine patch which is 7 milligram 14 milligram 21 milligram don't bother with the low patches please start your patients onto any one milligram unless they are intolerant of it velbuterans that is buprupeon 150 milligrams a sustained release the varnicline shantix 0.5 and 1 milligram these are your controller medications your reliever medications are your gum, losanges, mini losanges, nicotine nasal spray and our best friend the nicotine inhaler why isn't there a nicotine pill because it undergoes first pass metabolism and for the amount of nicotine pill that has to be taken orally it'll cause serious side effects so that is why there is no pill there's a patch the gum is not meant to be chewed on you're supposed to soften it and park it between your teeth and your cheek the losange you cannot suck on it because if you ever suck on a losange it is disgusting you're supposed to just park it between your cheek and your gum the nasal spray you can use it and then there is the oral inhaler which we really really like and our patients like they're really it's really both you're supposed to kind of suck on it like how we are sucking on a straw you're not supposed to take big breaths i tried it out and i took a big breath and my tobacco coach julia melamad saw how disgusted i was and how i was wheezing for quite some time after that so that thing is very harsh if you take a nice and deep breath so that's not how you you're supposed to use it so the things to remember for us is that the baseline nicotine levels produced by smoking are higher than the patch the levels of nicotine are six to ten times higher in smokers and vapors than any patch and gum use and this is with them smoking so all the data i'm telling you is with them smoking and because of the fast delivery in smoking the cardiovascular effects are much much much higher in patients who use cigarettes instead of nicotine replacement therapy and patients who use nicotine replacement therapy continue to smoke just produce their baseline nicotine levels not higher so let us take away our traditional teaching which says do not smoke with a patch it is incorrect the patch will not work if you do not smoke with it uh proprio prion tablet twice a day or zyban uh it's average seizure rate with this is still less than one is to 1000 i've shown you some of the things that are in there which they talk about medications which lower the seizure threshold i am forever uh talking to both the psychiatrist and the neurologist saying that the seizure threshold lowering with this is still very low but i do do not pick this as my first medication in patients of known seizure disorder of course hepatic impairment of course pregnancy at all since there's no data for this at all and the emergent neuropsychiatric system actually that has been debunked by the trial the most recent trial which is the eagles trial which looked at nicotine replacement therapy looked at placebo looked at uh shantics and looked at belbutron and found that the neuropsychiatric effects was same in everything including placebo and there was no increased uptake of neuropsychiatric effects or any other effects in any of this and that shantics was truly the best medication in helping people stop smoking again i have no financial connection with physo and in fact i don't let physo come anywhere near us at all um so vanmiklin or apo vanmiklin because as you know currently there's a shantics recall going on because some of their some of their shantics tablets were i mean capsules were kind of contaminated with uh mitrocina mines so because of that shantics is on a recall which is a really bad thing for us because our patients who are doing very well are relaxing and there is apo vanmiklin available this is the canadian generic form of it so it is available however not all pharmacies are carrying it the biggest problem with this is nausea nausea nausea nausea you have to tell patients that they need to take it with food that means they need to go to i-hop and eat a breakfast and take it not like a banana or not like a bar or something they really need to eat full breakfast and it works as the agonist antagonist right it works on the nicotine acetylcholine receptors and it is very very good in terms of both providing relief from the craving and the withdrawal symptoms so this is a very good update on looking at all the medications you can see here the bupropryan the nicotine gum the nicotine inhaler vanmiklin and you can see that clearly vanmiklin is really really good in getting people for abstinence rates so is the nicotine nasal spray the nicotine patch for six to 14 weeks also works very well and the nicotine inhaler but clearly vanmiklin takes the best thing we really don't use clonidin or not tryptoline and you can see that if you use the patch with other reliever medications it really has one of the best effects patch we use even vanmiklin with other medications that was not studied here so our clinic it's funded through the state grant thanks to the center of tobacco prevention and control it is a visit with a lung doctor me and a tobacco coach i julia malamad who i think is on the call and our nurse practitioner currently who also runs a lung cancer screening we discuss about the good bad and ugly of a tobacco journey we assess the severity of tobacco dependence we do patient directed treatment methods and we continue support with the tobacco coach and we use controller and reliever medications so here is a small summary of the patients we are seeing older patients as you can see for older patient 65 plus is not our major group our major group is actually 45 to 64 predominantly black population predominantly from the lower socioeconomic status um and that is their insurance mix a lot of different comorbidities that we are seeing here um we started in this is data from 2019 to july 2021 so patients who had less than 170 days follow-up and patients who had more than 170 day follow-ups you can see that we have managed to get people to get abstinent and quit and cutting down which is important for us and same here and i will show you the rates of being more abstinent which happens with compliance of medications we have the scale system where we look at what action stage of tobacco dependence they are in the positive of the neutral forms are if they are accepting they are acting on direction they have early abstinence they are changing their routine or self-directed abstinence and the negative ones are right here and as you can see here what happens is that when they have compliance with their medications whether it's partial compliance or complete compliance then they are much more likely to cut down or be abstinent let me shift gears to covert for a second higher smoking in the progression group with covert and than the recovery group higher case fatality rates in males and females and this is data from china which is thought to be related to smoking and basically higher rates of covert in men in italy spain and china were thought to be because of smoking and they are much more likely to contract other respiratory infections here is why because this is a non-smoker and here is how we look in terms of our mucociliary clearance and our permeability and our ability to have lower spread of viruses and effective immunity clearly you can see that what happens with covert and with smoking is that it produces more ACE2 so there's impaired mucociliary clearance more ACE2 receptors leading to cytokine storm so I think I have told you a lot about nicotine and its effect on the brain I've told you that ends is the old epidemic because we now have more heated tobacco products we need to stop shaming and start healing it is an important part of what we need to do it is not cessation because cessation means it's a one sided effect that means only your patient is supposed to take an effort you as a provider do not need to take an effort so it is treatment it's a liberation the treatments are mostly safe and can be used for extended periods and I'm happy to take questions on it typically we use shantix for at least three months and up to six months and nicotine patches we've used it much longer than that higher severity definitely requires a step up therapy and nicotine use possibly increases the risk of COVID-19 intensity and also what I did not share with you is some of the vaping data which also does that so that is our clinic that's our website you can click on the website and you'll be able to find us a tobacco coach Julia Malamand who has been there with me from the inception and who is really the backbone of this program our patients love her talking to her we provide medication assistance so we have nicotine patches and other nicotine replacement therapy thanks to the grant that we are able to give them not nicotine inhaler because it's a prescription medication but we also connect them to things like the Pfizer program which allows nicotine inhalers to be given to them free of cost depending on their income we do virtual and text coaching and education the follow-up visits are usually 8 to 12 weeks and I would like us all to think about stopping smoking more in this manner in a more positive manner than in the negative played ads played short ads or horribly wrinkled women and things like that so that's all I got so I'm going to stop sharing now