2016 Annual FOMA Convention Thursday Feb. 18, 2016

Weston Fl.

Dennis H. Penzell, D.O., M.S., F.A.C.P. Associate Professor Medicine

College of Osteopathic Medicine Nova Southeastern University

I HAVE NO DISCLOSURES

Objectives

• BE AWARE OF SPECIAL POPULATIONS

• BE ABLE TO USE DOUBLE NICOTINE THERAPY

• MEDS + THERAPY INCR. SUCCESS

• DESCRIBE WHY E CIGS NOT HEALTHY

• EXPLAIN 3 ILLESSES NOW ASSOCIATED

"Quitting smoking is the most important action they can take to improve their health now and in the future."

IQuit with AHEC 1-877-848-6696

ahectobacco.com

• Free In-person Tobacco Cessation Groups • Receive tools/strategies to quit and stay tobacco-free • Programs in English and Spanish • Friendly, respectful, supportive group setting • Free nicotine replacement therapy

FLORIDA QUIT LINE 1-877-U-CAN-NOW

• Counseling via phone or on-line services available.

• Quitline services in English, Spanish, Haitian Creole.

• Translation services for all other languages.

• Free starter kit of nicotine replacement therapy.

HOT OFF THE PRESSES:

ICD-10 Codes Former ICD- code 305.1

• F17.2 (Nicotine Dependence)

• Z71.6 (Tobacco abuse counseling, not elsewhere classified)

• Z72 (Tobacco use NOS)

• Z77.2 (Contact with & exposure to ETS)

• Z87.8 (History of nicotine dependence)

•And many more…

*Each of these codes are often used with modifier(s) to specifically define the type of tobacco use or exposure

Effects of Nicotine Patch vs Varenicline vs

Combination Nicotine Replacement Therapy on Smoking Cessation at 26 Weeks

JAMA. 2016;315(4):371-379. A Randomized Clinical Trial

Timothy B. Baker, PhD

Effects of Nicotine Patch vs Varenicline vs

Combination Nicotine Replacement Therapy on Smoking Cessation at 26 Weeks

• Among adults motivated to quit smoking,

• 12 weeks of open-label treatment with nicotine patch, varenicline, or C-NRT.

• No significant differences in biochemically confirmed rates of smoking abstinence at 26 weeks.

• The results raise questions about the relative effectiveness of intense smoking pharmacotherapies.

JOURNAL OF CLINICAL ONCOLOGY J of Clin Oncol Jan. 2016

Cig. Smoking Before and After Breast Cancer Diagnosis:

Mortality From Breast Cancer and Smoking-Related Diseases. Passarelli, MN

JOURNAL OF CLINICAL ONCOLOGY J of Clin Oncol Jan. 2016

• During a median of 12 years, 6,778 women died, including 2,894 who died as a result of breast cancer.

• Active smokers 1 year before breast cancer diagnosis were more likely than never smokers to die of breast cancer.

BENZALDEHYDE

COMMONLY FOUND IN E- CIG. VAPOR

Thorax. January 28, 2016. Kosmider L, Sobczak A, Prokopowicz A, et al.

Smokers of cherry-flavored electronic cigarettes inhale higher levels of benaldeyde than smokers of regular cigarettes.

• Benzaldehyde found in food and cosmetics.

• Safe to eat and apply to the skin.

• Inhaling linked to irritation resp pass and eyes.

• Researchers extracted the vapor of 145 e-cigarettes by using an automatic smoking simulator, trapped it in sorbent tubes, and analyzed it using liquid chromatography.

• Results showed that benzaldehyde was present in 74% of e-cigarettes tested, with cherry-flavored vapor containing the highest dosage.

• Researchers also noted that the level of benzaldehyde produced by 30 puffs of e-cigarette vapor was higher than that produced by a regular cigarette.

THE NUMBERS

• 18 of every 100 U.S. adults aged 18 years or older (17.8%) currently smoke cigarettes.

• 16 million Americans live with a smoking-related disease.

• 42.1 million adults in the United States currently smoke cigarettes.

• 480,000 deaths every year, or 1 of every 5 deaths.

• CDC :Current Cigarette Smoking Among Adults—United States, 2005–2013.. Morbidity and Mortality Weekly Report 2014;63(47):1108–12

• CDC: The Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion,

DEMOGRAPHICS National Health Interview Survey

• Gender: M>F • Poverty Status: BELOW POVERTY > above poverty • Sexual Orientation: GLBT • Tobacco and HIV: 50% w HIV • Disabilities: Ever smoked and to be current smokers.

Jamal A, Agaku IT, O’Connor E, King BA, Kenemer JB, Neff L. Current cigarette smoking among adults—United States, 2005-2013. MMWR Morb Mortal Wkly Rep. 2014;63:1108-12. •

WHY DO THIS?

“KIDS”

Almost 90 percent of adult smokers began at or before age 18.

U.S. Department of Health and Human Services, Preventing Tobacco Use Among Young People: A Report of the Surgeon General. 1994.

Annals of Allergy, Asthma and Immunology Mayo Clinic Children’s Research Center

September 25, 2015

• The risk for hospitalization doubles for kids with asthma who are exposed to secondhand smoke.

• 15 million kids age 3-11 exposed to SHS.*

*CDC: MMWR-2/3/15 , HOMA, ET AL.

Neighboring Apartments May Expose Kids to Cigarette Smoke

Findings support smoking bans in multi-unit housing.

By Amanda Gardner

• Children who live in smoke-free apartments but have neighbors who light up suffer from exposure to smoke that seeps through walls or shared ventilation systems.

• Apartment-dwelling children have 45 percent more cotinine.

*PEDIATRICS Vol. 127 No. 1 January 2011, pp. 85-92

Power of Intervention

• Cold turkey: yields 2% - 4% x

• Brief:1- 3 min. intervention= 3% - 6% quit

• Behavioral counseling: -dose related - quit rate increases with time spent -yields 10% - 15% quit rate

• Meds and counseling yields: 20% - 30%

©2004 Seton Health System

WHY IS QUITTING SO HARD?

Nicotine enters brain

Stimulation of

nicotine receptors

Dopamine release

DOPAMINE REWARD PATHWAY

Prefrontal

cortex

Nucleus

accumbens Ventral

tegmental

area

NICOTINE ADDICTION

• Tobacco users maintain a minimum serum nicotine concentration in order to – Prevent withdrawal symptoms

– Maintain pleasure/arousal

– Modulate mood

• Users self-titrate nicotine intake by – Smoking/dipping more frequently

– Smoking more intensely

– Obstructing vents on low-nicotine brand cigarettes

Benowitz. (2008). Clin Pharmacol Ther 83:531–541.

Irritability/frustration/anger

Anxiety

Difficulty concentrating

Restlessness/impatience

Depressed mood/depression

Insomnia

Impaired performance

Increased appetite/weight gain

Cravings

NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS

Hughes. (2007). Nicotine Tob Res 9:315–327.

Most symptoms manifest within the first 1–2 days,

peak within the first week, and subside within

2–4 weeks.

HANDOUT

SMOKING AND MORTALITY

Strong evidence between smoking and

• Infections,

• Hypertensive heart disease,

• Renal failure,

• Intestinal ischemia

• Other respiratory diseases.

SMOKING AND MORTALITY

• The rate of death from renal failure is twice

as high among current smokers as among

persons who never smoked.*

• Pinto-Sietsma SJ, Mulder J, Janssen WM, Hillege HL, de Zeeuw D, de Jong PE.Smoking is related to albuminuria and

abnormal renal function in nondiabetic persons. Ann Intern Med 2000; 133: 585-91.

SMOKING AND MORTALITY

• Current smoking is associated with an increased risk of death from hypertensive heart disease.

• The only category of heart disease not already

attributable to smoking.

• Lip GY, Felmeden DC, Li-Saw-Hee FL, Beevers DG. Hypertensive heart disease: a complex syndrome or a hypertensive

‘cardiomyopathy’? Eur Heart J 2000; 21: 1653-65.

SMOKING AND MORTALITY

• Smoking acutely reduces blood flow to the intestines*

• Evidence suggests that smoking causes risk factors that

can often lead to intestinal ischemia, including atherosclerosis, platelet aggregation, and congestive heart failure.**

*Unal B, Bilgili MY, Yilmaz S, Caglayan O, Kara S. Smoking prevents the expected postprandial increase in intestinal blood flow: a Doppler sonographic study. J Ultrasound Med 2004; 23: 647-53. ** How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General. Atlanta: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

SMOKING AND MORTALITY

• Cigarette smoke adversely affects immune fx.

• Mortality from infx. was 2x as high among

current smokers vs. never smoked.

• Risk incr. with smoking intensity, declines with increasing number of years since cessation.

• Arcavi L, Benowitz NL. Cigarette smoking and infection. Arch Intern Med 2004; 164: 2206-16.

SMOKING AND MORTALITY

• Mortality from prostate ca was 43% higher among current smokers.

• Giovannucci E, Rimm EB, Ascherio A, et al. Smoking and risk of total and fatal prostate cancer in United States health professionals. Cancer Epidemiol Biomarkers Prev 1999; 8: 277-82. • Huncharek M, Haddock KS, Reid R, Kupelnick B. Smoking as a risk factor for prostate cancer: a meta-analysis of prospective cohort studies. Am J Public Health 2010; 100: 693-701.

SMOKING AND MORTALITY

Significantly higher mortality from liver cirrhosis among smokers than among persons who never smoked.

STROKE

• The estimated increase in risk for stroke

from exposure to secondhand smoke is

about 20–30%.

• The Health Consequences of Smoking – 50 years of progress: a report of the Surgeon General. – Atlanta, GA. : U.S.

Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. p. 944

COLORECTAL CANCER

• The evidence is sufficient to infer a causal relationship between smoking and colorectal adenomatous polyps and colorectal cancer.

DIABETES

• The evidence is sufficient to infer that cigarette smoking is a cause of diabetes.

• The risk of developing diabetes is 30–40% higher for active smokers than nonsmokers.

• There is a positive dose-response relationship between the number of cigarettes smoked and the risk of developing diabetes.

RHEUMATOID ARTHRITIS

• The evidence is sufficient to infer a causal relationship between cigarette smoking and rheumatoid arthritis.

• The evidence is sufficient to infer that cigarette smoking reduces the effectiveness of the tumor necrosis factor-alpha (TNF-α) inhibitors.

Health Benefits After Quitting

cough, DOE resolve in weeks

exercise tolerance improves rapidly

bladder cancer: 50% reduction in 5 years

lung cancer: 50% reduction in 10 years

heart disease: 50% reduction in 1 year!

No increased risk of heart disease by 10-15 yrs

vascular disease: 50% reduction in 5 years

mortality rates = never smokers by 10-15yrs.

MEDICATIONS

Why Pharmacotherapy?

• Alleviates withdrawal:

– NRT: Maintains nicotine serum concentration at or above patient’s comfort level

– Zyban/Chantix: Mimics this effect

• Eliminates the immediate reinforcing effect of administering nicotine through smoking

• Gives patients the time to more comfortably break their habits/routines

Are all smokers the same with respect to dosing NRT?

Combination Medications

DOUBLE NICOTINE THERAPY

Combination Therapies

• Combination NRT

– Long-acting formulation (patch)

• Produces relatively constant levels of nicotine

PLUS

– Short-acting formulation (gum, lozenge, inhaler, nasal spray)

• Allows for acute dose titration as needed for withdrawal symptoms

HIGHER DOSE NICOTINE PATCH

• There is a dose-response effect

• Long-term abstinence improved

• Treatment-related adverse events are uncommon

• Withdrawal symptoms less with higher dose NRT

*Cochrane Database of Systematic Reviews 2005

Extended Use of Medications

• Unlike smoking, NRT does not contain non-nicotine toxic substances (e.g., “tar,” carbon monoxide, formaldehyde, benzene).

• Produce sharp surges in blood nicotine levels; and/or (c) produce strong dependence.

Randomized Trial of Reduced-Nicotine Standards for Cigarettes

Eric C. Donny, Ph.D., N Engl J Med 2015;373:1340-9.

• Cigarettes with lower nicotine content, as compared with control cigarettes, reduced exposure to and dependence on nicotine, as well as craving during abstinence from smoking, without significantly increasing the expired CO

level or total puff volume, suggesting minimal compensation. Adverse

events were generally mild and similar among groups.

CONCLUSIONS

• In this 6-week study, reduced-nicotine cigarettes versus standard-nicotine cigarettes reduced nicotine exposure and dependence and the number of cigarettes smoked.

2015 USPHS UPDATED RECOMMENDATIONS

Ann Intern Med. September 22 2015

• Behavioral and Pharmacotherapy Interventions: Tobacco

Smoking Cessation in Adults, Including Pregnant Women. • U.S. Preventive Services Task Force Recommendation Statement

• Albert L. Siu, MD, MSPH, U.S. Preventive Services Task Force*

USPHS UPDATED RECOMMENDATIONS

• The USPSTF recommends that clinicians

----ASK all adults about tobacco use,

----ADVISE them to stop using tobacco

----REFER-Provide behavioral interventions and

pharmacotherapy adults who use tobacco.

(A recommendation). Net benefit substantial

Pharmacotherapy

• Evidence is convincing that using 2 types of NRT

moderately improves achievement of smoking cessation over single forms and that the addition of NRT to treatment with bupropion SR provides

additional benefit over use of bupropion alone.

• The USPSTF found adequate evidence that the harms of pharmacotherapy, including serious cardiovascular adverse events and neuropsychiatric events, are small..

Combinations of Pharmacotherapy

DOUBLE NICOTINE THERAPY

Combinations of Behavioral and Pharmacotherapy

Interventions.

Combining behavioral and pharmacotherapy

interventions may increase cessation rates from approximately 8% to 21%.

USPHS UPDATED RECOMMENDATIONS

• The USPSTF did not identify any reports

of adverse events related to combinations of

behavioral interventions and meds.

ELECTRONIC DELIVERY SYSTEMS

E-Cigarettes DESIGN

BATTERY

‘VAPORIZING’ UNIT

Where heating occurs

CARTRIDGE Contains the liquid

nicotine solution

3 COMPONENTS:

'Vapers' Are 28 Percent Less Likely to Stop Smoking

The Lancet Respiratory Medicine Jan 2016

• Odds of quitting cigarettes were 28% lower in those who used e-cigarettes compared with those who did not use e-cigarettes.

• Association of e-cigarette use with quitting did not significantly differ among studies of all smokers using e-cigarettes (irrespective of interest in quitting cigarettes) compared with studies of only smokers interested in cigarette cessation

JOURNAL OF CIRCULATION BENOWITZ

Circulation. 2014;129:1972-1986

Health claims/ efficacy for quitting smoking are unsupported by the scientific evidence to date.

USPSTF QUESTIONS EFFICACY OF E-CIGARETTE USE FOR SMOKING CESSATION Annals of Int Med: September 22, 2015

• There is not sufficient evidence for experts to recommend for or against the use of electronic nicotine delivery systems for smoking cessation.

Electronic cigarettes (e-cigarettes) resemble tobacco cigarettes and are comprised of three components:

• A cartridge that resembles a cigarette filter.

• Atomizing device’ or ‘heating element’ which ‘aerosolizes the flavor solution’ and turns the liquid solution into the inhaled substance.

• Battery activates the heating element.

• Commonly contain nicotine, do not actually contain tobacco.

• Although some classes of e-cigarettes are marketed as nicotine-free products, even “nicotine-free e-cigarettes” actually do contain at least trace amounts of nicotine.

AEROSOL

VAPOR??? AEROSOL???

E-CIG “SMOKE’

is a suspension of fine particles of liquid, solid or

both in a gas.

gaseous state of a substance.

Electronic Cigarettes

• Both the particulate and gas phases are mixtures of chemical substances in e-cigarette aerosols.

• The e-cig aerosol simulates cigarette smoke.

• Following a puff, the aerosol is delivered into the user’s mouth and lungs by inhalation.

• Hoffman AC, Evans SE. Abuse potential of non-nicotine tobacco smoke components: acetaldehyde,

• nornicotine, cotinine, and anabasine. Nicotine Tob Res 2012;15:622–32 [

Electronic Cigarettes

• Aerosol is exhaled into the environment.

• Generate different physical and chemical characteristics during operation.

• Hoffman AC, Evans SE. Abuse potential of non-nicotine tobacco smoke components: acetaldehyde,

• nornicotine, cotinine, and anabasine. Nicotine Tob Res 2012;15:622–32 [

Electronic Nicotine Delivery Systems (ENDS)

• Varying nicotine concentrations in the solution generating the nicotine aerosol (also called e-liquid),

• Varying volumes of solution in the product,

• Different carrier compounds (most commonly propylene glycol with or without glycerol [glycerin]),

• Wide range of additives and flavors, and battery voltage.

• Quality control is variable,*,Design flaws, lack of adequate labeling

• Engineering differences result in variability in how e-cigarettes heat and convert the nicotine solution to an aerosol and consequently the levels of nicotine and other chemicals delivered to users and the air pollution generated by the exhaled aerosol.

• Trtchounian A, Talbot P. Electronic nicotine delivery systems: is there a need for regulation? Tob Control.

2011;20:47–52.

ENDS

• Lack of well-designed, randomized, controlled trials (RCTs) on ENDS that report smoking abstinence or adverse events.

• A critical gap in the evidence.

ELECTRONIC DELIVERY SYSTEMS

• Evidence is lacking and conflicting.

• The balance of benefits and harms cannot be determined.

• Given the established safety and effectiveness of behavioral and pharmacotherapy interventions, the USPSTF recommends that primary care providers direct patients who smoke to these other interventions.

ELECTRONIC DELIVERY SYSTEMS

• Inadvertent poisoning in children who mishandle nicotine cartridges is a concern.

• Poison center calls increased from 1 per month in 2010 to 215 per month in 2014.

ELECTRONIC DELIVERY SYSTEMS DUAL USE

Smokers are concurrently using e-cigarettes

New Study Reports High Levels of Formaldehyde in Electronic Cigarette Aerosols

• Study released by the New England Journal of Medicine reports finding high levels of formaldehyde in the aerosol of electronic cigarettes, leading the authors to conclude that the cancer risk associated with vaping is higher than that associated with smoking.

• (See: Jensen RP, Luo W, Pankow JF, Strongin RM, Peyton DH. Hidden formaldehyde in e-cigarette aerosols. New England Journal of Medicine 372;4, January 22, 2015.)

When heated and vaporized, propylene glycol

can form propylene oxide, an International

Agency for Research on Cancer class 2B carcinogen

• Laino T, Tuma C, Moor P, Martin E, Stolz S, Curioni A. Mechanisms of propylene glycol and

triacetin pyrolysis. J Phys Chem A. 2012;116:4602–4609.

Vaping in Public Places?

• Little research on exposures from secondhand or third-hand aerosols from e-cigs and the potential effects.

• Little research about the impact of allowing smoking in public places on the uptake of these products in kids and among those trying to refrain from smoking.

Society for Research on Nicotine and Tobacco Studies provide new evidence on ‘thirdhand’ exposure to nicotine,

accuracy of product labels

FRIDAY, FEBRUARY 7, 2014

• Analyzed three brands of e-cigs filled with varying nicotine concentrations.

• The e-cigarettes were smoked, or “vaped,” with a syringe in an exposure chamber.

• Nicotine levels on five surfaces of the smoking chamber were measured. The glass, floors, walls, windows, wood and metal.

Nicotine levels on surfaces

• Three out of four experiments showed significant yet varying increases in nicotine found on the five surfaces.

• The floor and glass windows had the greatest increases in nicotine residue.

• Concluded that future research should explore the risks of exposure to carcinogens posed by third-hand exposure from e-cigarettes.

It is not a safer option to swap regular cigarettes with e-cigarettes for young people, claims a new study.

Dean E Schraufnagel, MD at University of Illinois at Chicago,

• Although heavily promoted as a safer cigarette and an aid to quit smoking, electronic cigarettes and the nicotine they deliver pose particular risks to the developing brains and organs of children.

• Potential "gateway to addiction ??

National Youth Tobacco Survey of

Middle School and High School Students

2011, 2012, 2013

• Dr. Rebecca E. Bunnell, Office on Smoking and Health, National Center

for Chronic Disease Prevention and Health Promotion, Centers for Disease

Control and Prevention.

E-cigarette use was associated with increased intentions to smoke cigarettes.

• 2011-2013, the number of never-smoking youth who used e-cigarettes increased three-fold, from 79,000 to over 263,000.

• Intention to smoke conventional cigarettes was 43.9% among ever e-cigarette users and 21.5% among never users.

• Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users.

• Nicotine Tob Res (2014)First published online: August 20, 2014 Rebecca E. BUNNELL, ScD,

MEd

The greater the number of advertising

sources youth encountered, the more likely

they were to say they intended to smoke

cigarettes, a finding consistent with previous

studies.

Nicotine Tob Res (2014) August 20, 2014 Rebecca E. BUNNELL, ScD, MEd

E-Cigarettes Prompting Kids to Smoke

• Concerned public health advocates(World Health Organization) see e-cigs as a route to nicotine addiction.

• Possibly as a potential gateway to tobacco use in youth or nonsmokers.

• Reinitiation of tobacco product use by former users.

SO WHAT DO WE DO?

Summary of Current Recommendations for Clinical Guidance

• E-cigarette use should be included in our tobacco screening questions.

• Docs need education about e-cigarettes.

• We should be prepared to counsel our patients regarding comprehensive tobacco cessation strategies.

Summary of Current Recommendations for Clinical Guidance

• Patients should be separated into 3 treatment

categories based on their tobacco/e-cigarette use status.

• 1. Tobacco product users who are willing to quit should receive intervention to help them quit

• 2. Tobacco product users unwilling to quit at the time should receive interventions to increase their motivation to quit. (5As, 2As+R, Meds)

• 3. Those who recently quit using tobacco products should be provided relapse prevention treatment.

Summary of Current Recommendations for Clinical Guidance

• If a patient has failed initial tx., has been intolerant to or refuses to use conventional smoking cessation medication, and wishes to use e-cigs to aid quitting, it is reasonable to support the attempt.

• Benowitz Circulation 2014.

• Palozzolo: Frontiers in Public Health 11/2013

SAFETY

• There are as yet no long-term safety studies

of e-cigarette use, it may be appropriate to

advise the patient to consider setting a quit

date for their e-cigarette use and not plan to

use it indefinitely (unless needed to prevent

relapse to cigarettes).

Hookah (waterpipe smoking)

• Also known as – Shisha

– Narghile

– Goza

– Hubble bubble

• Tobacco flavored with fruit pulp, honey, and molasses increasingly popular among young smokers in coffee houses, bars, and lounges

Image courtesy of Mr. Sami Romman / www.hookah-shisha.com

FORMS of SMOKED TOBACCO PRODUCTS

HOOKAHS

• “Hookah smokers widely but mistakenly believe that the pipe is a harmless alternative to other forms of tobacco smoking”

--Tracey Barnett-lead researcher UF College of Public Health

HOOKAHS

• During a typical 60 minute hookah session,

users may smoke the equivalent of 20 or more

cigarettes…

• Uyanık B, Arslan ED, Akay H, Erçelik E, Tez M. Narghile (hookah) smoking and

carboxyhemoglobin levels [letter]. J Emerg Med. 2011;40(6):679

Hookahs

• = tobacco smoke.

• Same diseases.

• Risk of lip cancer.

• Ingest about 100 times

more lead than a cig.

HOOKAHS

• Delivers 11x more carbon monoxide than a cig!

• High levels of carcinogenic toxins and heavy metals.

• While water in the hookah pipe does absorb some

nicotine, some smokers are exposed to enough to cause addiction.

ICD CODE TRANSITION

• ICD-9 code 305.1 (tobacco use and dependence) will transition to the new ICD-10 codes:

F17.2 (nicotine dependence), 099.33 (smoking complicating pregnancy, childbirth, and the puerperium), P04.2 (newborn affected by maternal use of tobacco), P96.81 (exposure to environmental tobacco smoke in the perinatal period), T65.2 (toxic effect of tobacco and nicotine), Z57.31 (occupational exposure to environmental tobacco smoke), Z71.6 (tobacco use counseling, not elsewhere classified), Z72 (tobacco use not otherwise specified (NOS), Z77.2 (contact with and exposure to environmental tob smoke) Z87.8 (history of nicotine dependence).

Summary

1.The numbers 2.Its an addiction 3. Multiple associations with medical illnesses. 4. Medications: DOUBLE NICOTINE THERAPY 5. DOUBLE NICOTINE THERAPY AND COULSELLING 5. E cigs-We don’t know but don’t look good. 6. Hookahs 7. New Codes w ICD 10

THE END!!!