Smoking and Vaping Cessation

Listen in as our expert panel discusses evidence-based approaches to help patients quit smoking, vaping, and using other nicotine products. You’ll gain practical insights on medication selection, combination strategies, and tailored approaches for helping patients break free from nicotine addiction.

Special guest:

• Robin Corelli, PharmD, CTTS, FCSHP
  • Professor of Clinical Pharmacy
  • School of Pharmacy
  • University of California, San Francisco

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Stephen Carek, MD, CAQSM, DipABLM
  • Clinical Associate Professor of Family Medicine
  • Prisma Health/USC-SOMG Family Medicine Residency Program
  • USC School of Medicine Greenville
• Craig D. Williams, PharmD, FNLA, BCPS
  • Clinical Professor of Pharmacy Practice
  • Oregon Health and Science University

None of the speakers have anything to disclose. 

This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in November 2025.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources related to this podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Chart: Smoking Cessation Drug Therapy
• FAQ: E-Cigarettes and Vaping
• Chart: Dos and Don’ts With Patches
• Article: Help Patients Send Their Vaping Habits Up in Smoke 

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Transcript

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00:00:07 Robin Corelli:

So what happens is it makes smoking or using nicotine these nicotine delivery systems less pleasurable. Patients summarized it really nice to me before I said, you know, when I used varenicline, I, I felt like I was smoking a cardboard cigarette. I didn't feel anything like what I thought, what am I doing?

00:00:29 Craig Williams:

I usually give patients like, here's the menu of treatment options varenicline and bupropion. Varenicline like probably the best medicine used for this. You may get some weird dreams out of this. If they have co-morbid behavioral health disorder, depression anxiety. Then I'll introduce Wellbutrin like, hey, there's this other medicine that may help manage your depression a little bit better. Counsel on the side effects. The benefits from the medication.

00:00:55 Narrator:

Welcome to Medication Talk, an official podcast of TRC healthcare. Home of Pharmacist Letter, Prescriber Insights and the most trusted clinical Resources. On this episode, listen in as our expert panel discusses evidence based approaches to help patients quit smoking, vaping, and using other nicotine products. You'll gain practical insights on medication selection, combination strategies, and tailored approaches for helping patients break free from nicotine addiction. Our guest today is Doctor Robin Chiarelli, professor of clinical pharmacy at the UCSF School of Pharmacy and a certified tobacco treatment specialist and provider in the UCSF Health Fontana Tobacco Treatment Center. You'll also hear practical advice from members of Trc's editorial advisory board, Doctor Stephen Karrick from the USC School of Medicine, Greenville, and Doctor Craig Williams from the Oregon Health and Science University. This podcast is an excerpt from one of Trc's monthly live webinars each month. Experts and frontline providers discuss and debate challenges in practice. Evidence based practice recommendations and other topics relevant to our subscribers.

00:02:08 CE Narrator:

And now the CE information.

00:02:12 Narrator:

This podcast offers continuing education credit for pharmacists, pharmacy technicians, physicians, and nurses. Please log in to your pharmacist letter, pharmacy Technicians letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose. Now let's join TRK editors, Doctor Stephen Small and Sarah Klokkers and start our discussion.

00:02:42 Steve Small:

So let's dive deeper into medication therapies we have for smoking cessation. I'm sure many folks are familiar with FDA approved therapies that include varenicline, nicotine replacement therapy, or NRT, things like nicotine patches and gums and bupropion. But how do these stack up? And maybe. Robin, to start with you, what is the most effective option for smoking cessation?

00:03:06 Robin Corelli:

Well that's always that's the question that patients always I want the best one. But honestly it's the one that the patient's going to take. Actually in the manner that it was found to be effective. Right. You got to use the right dose, the right drug, and you've got to follow it in the instructions. But other factors like can they afford it. Is it on their insurance. But I would say, you know, the most effective options if you look at randomized controlled trials, we have just a treasure trove of evidence. There's almost four hundred and fifty randomized, placebo controlled trials with medications for smoking cessation. And what we do know from those trials is that there are some medicines that are more effective, or at least in randomized controlled trials, and that would be varenicline and then combinations of nicotine replacement therapy. Those two about double a patient's chances for quitting relative to using placebo. That's not to say that bupropion, the gum, the lozenge and the nicotine nasal spray aren't effective, but they bump the odds by forty percent. So I don't want this group to leave thinking that those are not reasonable choices.

00:04:17 Steve Small:

And along with that, how does varenicline work and how should it be used to get that best chance at successfully quitting?

00:04:25 Robin Corelli:

Okay, varenicline I would say it's the newest drug. But my goodness we're going on. It's been available for twenty years now. Didn't contain nicotine. And what we know about this is it's a partial nicotinic agonist. Okay. So what that means is that as a partial agonist, it both mimics and blocks nicotine's effects in the brain. It binds with very high specificity and selectivity to the alpha four beta two nicotinic acetylcholine receptors, and what it does is as a partial agonist, it stimulates the release of dopamine, similar to nicotine, but not as strong. In fact, it's about fifty percent of that of nicotine. So it's sort of a weaker form, but it's still alleviates symptoms of withdrawal. Now varenicline has a long half life too, which is nice because when dosing we dose it twice a day. So it's blocking the binding of nicotine. Should someone slip up and smoke or vape or use a nicotine pouch or dip? So what happens is it makes smoking or using nicotine these nicotine delivery systems less pleasurable. Patients summarized. It really nice to me before I said, you know, when I used varenicline, I felt like I was smoking a cardboard cigarette. I didn't feel anything like what I thought, what am I doing?

00:05:47 Steve Small:

What are risks with varenicline. Is there any patient populations you feel should not use it? 

00:05:55 Craig Williams:

You know. If we've learned it's safer and safer drug as we use it more and more, we get less concerned about some of the early concerns about it. But the only contraindication is a hypersensitivity to the compound. People might be familiar with. There were some early neuropsychiatric concerns with the medication in terms of if it could potentially worsen depression or even be associated with suicide. So it looks like as we use the drug longer, we're getting less concerned about the early neuropsychiatric adverse effects. But we really don't have the same concerns psychiatrically, that we did fifteen years ago when we were learning about this drug together.

00:06:34 Robin Corelli:

Yeah, I'd like to piggyback on that, Craig. So in two thousand and nine is when the FDA. There were too many reports of all of those neuropsychiatric symptoms. In fact, the FDA Mandated the manufacturers of varenicline, and some people don't know this, but also bupropion because they were also neuropsychiatric signals with that compound as well. So they did an incredibly well designed trial called the Eagles Trial, which was published in twenty sixteen and led to the removal of the boxed warning, which there are very few drugs that had a boxed warning removed. So I think, Craig, I agree with you. We're getting more and more comfortable with this as time goes on. And again, it's it's such an effective agent that we don't want to reserve it for people to fail. Other treatments that should be used with confidence. First line. And if you're working with a patient that has underlying neuropsychiatric, you should certainly be working with the partner, your provider. If you're a pharmacist.

00:07:37 Steve Small:

And we have another audience question, Robin, one subscriber mentions that they see patients reporting nausea with varenicline. Can you give us some info on that side effect?

00:07:48 Robin Corelli:

Probably the biggest issue in starting varenicline is the dose dependent nausea, which is why we recommend that people start slow with this. And the other key caveat is that people should take each dose with a meal or a full glass of water. Those strategies in and of themselves significantly mitigate the nausea with varenicline. So that is something that's really, really important. But what about somebody who's now gone up to the one milligram twice a day and they're having nausea? Well, sometimes what we need to do with that is to cut back and decrease typically will decrease the night time dose or the evening dose.

00:08:33 Steve Small:

And as we were talking about those risks and some of that reassuring data, we do have a subscriber question asking how long can patients use varenicline. They mentioned they've seen patients on it for over two years. Robin, what's your take on that question?

00:08:48 Robin Corelli:

Well, my take on it as we know it can be safely used. In fact, it's FDA labeled for six months, right? And but we're seeing a more, more off label use with this. In fact, that's what we use with nicotine replacement therapy, too. This is evolving that we're getting more comfortable with using these medications long term in selected patients. Certainly we want patients not using any of these medicines, you know, getting completely off of them. However, if the alternative if they relapse, well, you know that we're finding that the side effect profile for varenicline is it actually is well tolerated over time. And so it's not uncommon to see patients on them. We have patients coming back in the clinic that have relapsed that were on varenicline for a year. And then they went off it in relapse. So guess what. We recommend it again. Longest that I've seen somebody on varenicline was almost two years.

00:09:46 Craig Williams:

Yeah. Just add briefly to that. The I tend to think of and with bupropion as well, just thinking about the kind of chronic oral therapies. So yeah, I know I totally agree with the comments from Robin that we should be comfortable with certainly varenicline longer than that six month label time. I think the nice thing is when patients have stopped for a while, some will really get over the cravings and not need the therapy anymore. So like the short answer is feel comfortable using these very long term for patients where we think we still need them. But if they're not working, twelve weeks is my kind of usual response for both varenicline and bupropion, for if things aren't getting better and we're twelve weeks in, let's think about things differently.

00:10:28 Robin Corelli:

Yeah, absolutely. Craig. If it's not working by that point, we need to do something else and talk about combinations of treatments. And probably for some of those really adding in the behavioral component. We didn't mention that there's two parts to nicotine dependence and there's two parts to treatment. Medicines alone can be effective, but they are infinitely better when you combine them with good behavioral counseling and coaching. So I think that's another piece that we're we're focusing on the medicines. But that really is such a critical component because of the behavior. And then the other thing to consider too, and this is something that when you're just working with patients to really, you know, everybody's different. And even among an individual their quit attempts may be unique. And so how people metabolize nicotine, what the level of upregulation of nicotine receptors in the brain, you really have to sort of throw out this is not a recipe or a cookbook. You really do need to tailor it.

00:11:26 Steve Small:

And let's say a patient is ready to stop varenicline. We have a subscriber asking how that patient should stop the regimen. For example, does it require a taper?

00:11:37 Robin Corelli:

Well, I would say, by and large, the majority of people who are using varenicline are using it in the standard dose for twelve weeks, and that's the majority of patients and have excellent results. However, there are a good proportion that need to use it for longer. But for varenicline, we don't normally taper. As I said before, we just stop, but we have had individuals that have wanted to do that. So and we kind of do sort of a reverse and we'll go slowly. So if someone's been on it for six months and they were on a milligram, you know, twice a day we can go down to a half a milligram twice a day and we can carry that for a certain time checking in. That's just basically a reverse. But there's no there's no magic for this. You're going to be working with that person closely. But the goal is to be, you know, to be off. As pharmacists, we want people in the least amount of medications possible to control all of their conditions. Taking a look at everything and this this would be no different.

00:12:38 Steve Small:

Really great discussion there on varenicline. And let's take some time to talk about NRT. We have nicotine patches as a long acting option, but also short acting replacement medications such as gums, lozenges, and even a nasal spray option. With these in mind, Robin, one subscriber asks, what's the most effective way to use nicotine replacement therapy?

00:13:01 Robin Corelli:

Nicotine replacement therapy is, you know, that's you know, by and large, the number one medicine that's used is the nicotine patch. Seventy percent of all pharmacologically assisted quit attempts use the patch. But I would say one of the things that's really important with nicotine replacement therapy, particularly over the counter where people purchase this without any professional support, you happen to have that or you do recommend it. Please advise people to read the instructions. Okay, now that's for some people. What are you. Are you kidding me? Why would I read the instructions on gum. I know how to chew gum, but as we all know, the gum and the lozenge have to be used in a very particular way for them to be effective. So that is something to just to drive home that it's really important to talk about proper use of chewing the gum correctly. You know that Chew Park technique. Making sure they use the right dose. And if they're using the gum or lozenge and they smoke within thirty minutes of waking, they should be using the four milligrams strength. If they're smoking more than half a pack a day of cigarettes, they should start with the twenty one milligram strength dose. You know I'm talking about monotherapy, but big believer in using NRT in combination. Using a long acting agent like the patch which delivers its stated dose continuously across the skin over twenty four hours, you know, basal level and then using short acting for situational urges or as needed for cravings, so you can have gum or lozenge in the background every one to two hours only if you need it. And that is a light bulb moment for patients. And I would really stress, which is one of the reasons why I believe that some of the trials with the gum, lozenge and even the nasal spray are less or lower. Those are short acting and they don't use them frequently enough. If you are only using the gum or lozenge, you really need to be using a piece every one to two hours while you're awake. That's about nine pieces a day. I can't tell you how many times when we talk with patients, the gum doesn't work for me. You want to probe that? Well, tell me how you use the gum. And what strength did you use? Oh, I use the two milligram, and, I don't know, a couple of pieces a day. Well, and someone who's, you know, is smoking their first cigarette within thirty minutes of waking, they've under dosed themselves and they've clearly not used the minimum necessary to help with alleviating symptoms of withdrawal.

00:15:36 Craig Williams:

Aid on that brief, if I can, Steve, to earlier conversation of how to maybe help our community pharmacy colleagues kind of engage in this. I think it's wonderful that the gum and the logins are over the counter. And that's a wonderful time to engage with these patients, our community colleagues. That's an obvious open door to have a brief discussion of how they're using it to why they're using it, how long they've been using it. And to Robin's point, maybe that by itself is not the optimal therapy. And some things do still require a prescription, but that's a wonderful way to start the conversation with a patient on the community side.

00:16:09 Steve Small:

And Steven, what are the circumstances where maybe you would not use NRT in your patients? Are there any examples there to point out for the audience? 

00:16:20 Steven Carek:

Yeah, for most patients, unless they have like some sort of like contact reaction to some of these, to like the patches is probably the one thing that I may occasionally see. I'm not really sure of any sort of specific circumstances where this would necessarily be harmful for patients, as long as you're appropriately dosing it and having the patient use them correctly.

00:16:39 Robin Corelli:

Yeah, that's and it's true. These are incredibly well tolerated. There are some populations for someone that has temporomandibular joint disease. And when patients are diagnosed with that they're told usually that gum isn't a great idea anyway. Of course, the nicotine replacement therapy gum is very viscous, so it can aggravate that. I don't want to spend too much time on the nasal spray. It's just not used because it's expensive and it has a steep learning curve. So individuals that have sinus conditions or allergic rhinitis and that spray is extremely irritating not contraindicated. But it's it's really generally not well tolerated in that population.

00:17:20 Steve Small:

And then related to that briefly, one subscriber asked what are risks of using nicotine gum long term? For example, they're worried. Can it be addictive? What's the quick take on that?

00:17:32 Robin Corelli:

One thing about nicotine replacement therapy, in contrast to nicotine delivery from vaping devices and cigarettes, is you don't have that immediate surge of nicotine levels. In fact, that's one of the problems with these are their blood levels are lower and slower, which really markedly reduces the chances for addiction with these compounds.

00:17:58 Craig Williams:

Yes, I know Steve, that's I mean, I almost think of there not being risks to long term nicotine gum or lozenge. So it's just the nicotine drug itself is not where the concern comes from in vaping and cigarettes. So. And if this is what's helping the patient maintain abstinence from those other more harmful products. And I don't really think of there being long term risks. Periodically cardiovascular things have popped up in literature, but it's really just not there when they're used in appropriate doses. And there's really no long term side effects, certainly nothing that comes close to the vaping and smoking that we're hoping them to stay off of.

00:18:34 Steve Small:

And let's take a moment to talk about bupropion. It's also used as an antidepressant. But what's its role in smoking cessation.

00:18:43 Robin Corelli:

Bupropion and monotherapy with nicotine replacement therapies definitely works. And the right patients. Some people have a strong predilection. Somebody may have underlying depression when they quit in the past. And that might make bupropion a better option. But I would say that the best options that most tobacco treatment specialists are leaning towards, and certainly it's our practice. And UCSF is to encourage the use or prescribe the use of varenicline or combinations of nicotine replacement therapy, because we know that those have the best results in clinical trials.

00:19:18 Steve Small:

And Craig, I wanted to get your thoughts here on risks with bupropion. Are there certain patients who shouldn't use this med? For example, one subscriber is asking if you should avoid it even if a patient had one seizure in the past.

00:19:33 Craig Williams:

Yeah, that's a great question. And it's maybe a bit more complicated than this question we had for varenicline. You know, again, it has a standard. If you have hypersensitivity to this agent, you know, don't use it. But of all the stimulating antidepressants we use this is the biggest risk for seizures. That being said, almost all the cases are in cases of overdose of this medication. So I mean it's still listed as a relative contraindication. And it comes up so seldom in practice that patients with a history of known epilepsy who now we're trying to work on smoking cessation for. But that would certainly give me caution using this agent. Not to say it's a hard contraindication, but I'd have to make sure I was comfortable with that patient, that they understood those risks. But, you know, seizures would be a not a hard stop, but a pretty firm soft stop for us for this medication.

00:20:27 Steve Small:

Great. And as we're talking about bupropion here, we have a subscriber question asking can you use bupropion XL instead of SR for smoking cessation.

00:20:39 Robin Corelli:

Yeah, that's a common question. The answer is yes. And I guess it's no shock to any pharmacist who looks at the pharmacokinetics. What are the blood levels. Well, you have. It's just a sustained release and it's once a day. So it's probably better for adherence. There actually was a study published out of MD Anderson a couple of years ago where they looked at that in patients with cancer and found that they basically performed identical. So people should have no problem using the XL formulation for once a day and take advantage of the once daily dosing.

00:21:11 Steve Small:

As you're tailoring bupropion or other therapies together. What kind of combinations do you see? We've got a lot of subscriber questions about can you use varenicline plus NRT, bupropion plus varenicline all three together? What's the take on that fortune?

00:21:26 Craig Williams:

People are smoking less and I use the analogy like in diabetes we often kind of a short term and long term insulin. And there's a short term and long term therapy for smoking cessation. And either bupropion or varenicline is your kind of long term. And almost always we're recommending combining that with the short term nicotine replacement product. So I never would start both together and have to strain to think of a patient I had on both varenicline and bupropion, along with nicotine products I tend to think of as one or the other along with nicotine. It's not a contraindication to potentially have both on board, but it's just not a strategy that we certainly used in our practice. But very commonly it's one of those and generally preferentially varenicline along with the short term nicotine replacement product.

00:22:15 Robin Corelli:

We actually do use a fair amount of combinations. I think the population that we tend to see tends to be a little more recalcitrant and is we're using it, but as a first line approach. No, I would not use varenicline and bupropion as a first line approach. It'd be somebody that's not responding that you would think to maybe augment and boost. Have we had people on triple? Yes. Is that common? No, but it is an option. So I think it's just but the literature is mixed on that. And again with bupropion and varenicline varenicline and nicotine replacement therapy the results are mixed. So as a tobacco treatment specialist will reserve those. But I would agree that this is not a first line treatment approach that you would start with somebody.

00:23:01 Stephen Carek:

Yeah. As you all alluded to, it's I think previously it's like we always try to figure out what's the best medication to treat the most conditions, at the least amount of risk to the patient. And so definitely I always frame the conversation with nicotine replacement therapy plus likely some sort of long acting medicine using Craig's algorithm. There's usually some sort of short term medication we use just for those cravings. And then we think the big picture, long term medications. And definitely over the past few years, I've been including more frequent for that long term medication. That's my sort of first go to. However, I usually give patients like, here's the menu of treatment options varenicline and bupropion. Varenicline like probably the best medicine used for this. You may get some weird dreams out of this. If they have comorbid behavioral health disorder, depression, anxiety. Then I'll introduce Wellbutrin like, hey, there's this other medicine that may help manage your depression a little bit better. Counsel on the side effects, the benefits from the medication. But as I said, my general orders varenicline plus NRT first and foremost. But they have that underlying depression. There's a bit of weight. Maybe they're just really against any of the potential psychiatric or behavioral side effects that varenicline could have in Wellbutrin, I think is a very reasonable option for patients to be on. I usually don't start them both at the same time. We'll kind of see how they go for a few weeks. If we feel like we're not getting the progress that we want, maybe we'll add on the second agent or even have a conversation when you switch to a different agent.

00:24:21 Steve Small:

Great discussion there. Now over to you, Sara.

00:24:25 Sara Klockars:

I want to ask a few more audience questions. We've had a lot of questions about vaping and the nicotine pouches. So, Robin, can you answer this one? Are certain forms of nicotine safer than others?

00:24:39 Robin Corelli:

I just want to say that are they're more harmful? Yes. Anything that is combustible tobacco is clearly the most harmful because you're getting just, again, all those host of chemicals that are generated from burning organic materials. So clearly cigarettes, cigars, pipes, those are far more dangerous than would be a nicotine pouch which is just nicotine salt. And then, of course, we have nicotine replacement therapy, which I would put on the other end of the spectrum, which is we know is safe and sort of that squishy middle in my mind is the things like nicotine pouches, vaping, iQOS. You may have heard that's Philip Morris new heat not burn tobacco product. And that is where we don't know. We'll see what happens over time with these. Are they harmful? Are they harmless? I like to tell patients they are possibly less harmful than smoking. I believe they are less harmful. Um, but they're not harmless. And we're seeing some emerging evidence with the effects of vaping relative to smoking. And we know that vaping does have some concerns for cardiovascular disease. And we do know that when your dual use, that actually can be worse than smoking. So the jury is out. We need to know more about that. Uh, my advice to people is to not be using any of these things because honestly, the vaping Devices that are on the market today. You know, they're largely manufactured in countries that have little to no regulation, and you honestly don't know what you're getting. The nicotine pouches and this is just another mode of delivery. And of course, the tobacco manufacturers, this is their next vista. They are all in on the nicotine pouches as what they're calling a harm reduction strategy, when we don't know their full effect of their harms yet because it hasn't been studied.

00:26:39 Craig Williams:

Yeah. I'll say a couple comments. We rarely recommend the pouch. The two times I can remember in recent memory it was to get people off chewing tobacco. So and they just that sensation of putting something there and it just it seemed to work well for them. But otherwise for the nicotine replacement products we have, this would not be something I'd recommend. I share Robin's thoughts. I think vaping in the long run probably is safer than smoking, but there's no way I can feel comfortable recommending someone combust. You know a cartridge put in a vape pen. None of those are FDA approved. I don't know where they're coming from. And, you know, out on the West Coast, we've certainly had a proliferation of those stores, and we've all seen some pretty horrible consequences of what happens when you combust that liquid, inhale it into your lungs. So I do think if we had a, you know, an FDA approved what we know is safe, you know, vaping liquid that was probably safer than smoking long term. But until we have that, it's just not something we can recommend if patient says they're going to try it. You know, we say, you know, go for it. But they do think it's probably safer than smoking. But a very hard thing I think for providers to be recommending.

00:27:48 Robin Corelli:

Can I just add on to that, though, that there's a conundrum with that, at least in the public health domain as it relates to vaping, because we know smoking is so dangerous, and there are studies that show that people can stop smoking by using vaping. In fact, the United Kingdom has embraced that. They recommend this as an option for people who are unable to quit with using traditional therapy. But I would argue that you really need to probe deeper. Are they using those conventional therapies appropriately? In fact, I just heard in the United Kingdom the proportion of people vaping actually exceeds the among adults smoking. So they again have really touted this. And we'll see what happens across the pond as they say. I think we would be hard pressed to recommend. I don't recommend vaping as a mode of smoking cessation. I try to optimize the first line therapies. I'm open to that possibility. There could be such a case, but I've been able to optimize treatment with our existing armamentarium and not gone down that path.

00:28:57 Sara Klockars:

Stephen, do you have anything to add about what's been helpful for your patients that may come in vaping or using pouches.

00:29:06 Stephen Carek:

I always encourage them to think of a goal of not using these any of these, because while they may be less harmful than smoking, I can guarantee you that they're healthy in any sense or beneficial for you in any way and sort of framing around that, definitely. You know, if you feel that this is going to be a mechanism like, hey, if you find that you're smoking socially, tobacco socially a lot, and using a vape pen will at least allow you to continue to participate socially. And I can say that's that's fun. That seems like a reasonable thing. We can continue to think through medication management strategies, replacement therapy, other tools that we have available to us to help navigate some of those things. And also, yeah, I just see sort of exponential increases in use of the nicotine pouches. The vape pens, as I alluded to, one, is I think we just probably need to do a better job screening for a lot more of these things. I think we're so regimented in screening for tobacco. I think screening for these things a little more thoughtfully, too. I know those can be overlooked at times and then just helping redirect people on just kind of maybe the health consequences that things like that could have. I often worry about sort of this nicotine mediums being just a gateway to tobacco use eventually down the line, in which case we're in a worse spot than we are at the current.

00:30:17 Robin Corelli:

Stephen, I'm glad you mentioned that, because I think health care providers tend to ask about smoking only. And that's clearly these other forms are emerging and increasing prevalence of use, especially among young young adolescents and young adults.

00:30:32 Sara Klockars:

Oh, that's a great transition to our next audience question. How do you start nicotine replacement therapy for patients trying to stop vaping? This is becoming an.

00:30:44 Robin Corelli:

Increasingly common question that health care providers are navigating. Someone who's coming in, who's never smoked but is vaping now and wants to quit vaping, and there are going to be people that use successfully quit smoking by transitioning to vaping. So how do we approach those? We have to really think about it. It's a nicotine addiction. So really any of the drugs could be used. So my recommendation is if you're using nicotine replacement therapy, first question is to ask, were you smoking before you were vaping. And if someone says yes well you can actually dose them as you would with their former smoking pattern was. But if they don't then it becomes a little more tricky, right? Because you really have no way of knowing. But if they're not, and I have to say, I'm going to give a plug to the pharmacist letter this year or this organization was, and to my knowledge, the first that actually came out with dosing recommendations for providers. And this was probably five years ago, right ahead of the curve. And you know what? The recommendations are still accurate to this day. We do recommend that people estimate the amount of nicotine that they're getting from their vaping device. So ask the patient, what device are you using? Show me on the label. You can look up on the web to see. Most of these are five percent nicotine solutions, but they vary. So you need to have that information and then ask, how many of these devices do you go through in a week? I'm using a geek bar and it has, you know, ten mils and I go through one a week. Right. As an example, you're just doing your basic pharmacy calculations. If it's a five percent solution and they're using one of those, one of those ten mil devices a week, you know, they're getting about on average about seventy milligrams a day. Okay. Which wow, you think about that. That's or at least that's what's in the device. But how much is actually absorbed. We don't really know. It's it's really hard because you have to it's these are all so different and they're not have the same regulatory controls that tobacco companies have over their cigarettes. So I would say we know it's going to be probably more than someone who's smoking a pack a day, but I don't know. So I'm I would always start someone on that with at least a twenty one milligram patch, and I would start them on a short acting nicotine gum or lozenge based on their time to first cigarette or vape. They vaped within thirty minutes of waking. I would use a four milligram gum or lozenge and I would highly, highly recommend frequent and early contact because someone who's using that much nicotine might be a candidate for two patches, and that's I always warn patients about that. You know, I think this will this will be a starting regimen. And let's see how you do, because this might not be enough. And we may need two patches. And patients are often, oh gosh, I don't want to put two patches on. That's too much. No, we're not going to start with that. We're going to be able to estimate, if you're using the gun, that we can determine how much of an additional patch might be necessary. So laying that foundation. But let me also emphasize that varenicline actually has evidence in controlled clinical trials in adult and youth populations for vaping cessation. Actually, over the past year, two very well-designed trials showing evidence with varenicline. So that's another one that you can recommend with confidence for vaping cessation. Of course, we talked about cytosine cytisinicline that one has an ongoing trial for vaping cessation as well. So that's another one to consider. Bupropion. There's no controlled trials. But would I use that. That's a potential option as well. We don't have evidence that we know with nicotine addiction. So bupropion and nicotine replacement therapy are all viable options. And I would say another along those lines for people that are using snuff, using smokeless tobacco, that there's data with using varenicline in that population as well. So switching to a nicotine pouch will at least reduce, in theory, some of the risk for some of the nitrosamines that are present in some of this moist snuff and chewing tobacco, but it doesn't address the underlying addiction to nicotine. So that's where, you know, we're in a clean is another option there, too.

00:35:28 Narrator:

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