Tackling Tobacco Use Disorder: Challenges, Innovations, and E-Cigarettes

In this episode of ASAM Practice Pearls, Dr. Peter Selby and Dr. Nancy Rigotti explore current and emerging strategies for treating tobacco use disorder (TUD). They discuss the latest pharmacological interventions, behavioral approaches, harm reduction strategies, and the evolving role of e-cigarettes in smoking cessation. 

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Host

Peter Selby, MBBS, CCFP(AM), FCFP, FASAM 

Dr. Peter Selby is a Senior Scientist and Senior Medical Consultant at the Centre for Addiction and Mental Health (CAMH) and Vice-Chair, Research, and Giblon Professor in Family Medicine at the University of Toronto. His research focuses on innovative methods to understand and treat addictive behaviors and their comorbidities. He utilizes technology to scale and test health interventions, with his cohort of over 400,000 treated smokers in Ontario serving as an example. Dr. Selby has received over $100 million in grant funding from CIHR, NIH, and the Ministry of Health and has published more than 200 peer-reviewed articles. His most recent research program utilizes a Learning Health Systems approach to investigate how technology-equitable, collaborative care can enhance the delivery of evidence-based interventions to the patient while providing a more satisfying care experience for patients and providers across systems.

Expert

Nancy Rigotti, MD 

Dr. Rigotti is a general internist and Professor of Medicine, Harvard Medical School. Her research aims to reduce tobacco-related diseases by improving the range and delivery of tobacco use treatments, especially in health care systems. She founded the Massachusetts General Hospital's Tobacco Research and Treatment Center, which evaluates tobacco treatment interventions in outpatient and inpatient health care settings in the U.S. and beyond (i.e., India, South Africa).  Additionally, she evaluates the risks and benefits of electronic cigarettes and has evaluated safety and efficacy of cytisine/cytisinicline, a new pharmacotherapy, with the goal of gaining its approval for use in the U.S.

📖 Show Segments

• 00:04 - Introduction 
• 00:18 - Case Scenario: Challenges in Treating TUD
• 01:50 - Exploring First-Line and Second-Line Treatments
• 03:17 - Combining Treatments for Better Outcomes
• 05:13 - Motivating Patients and Harm Reduction Strategies
• 08:43 - Controversies and Considerations with E-Cigarettes
• 18:16 - Future Directions in Tobacco Addiction Treatment
• 21:55 - Key Takeaways
• 23:20 - Conclusion and Additional Learning Opportunities

📋 Key Takeaways

• First-line treatments include varenicline and combination nicotine replacement therapy (NRT), while bupropion and single NRT serve as second-line options. Combining medication with behavioral support improves effectiveness. 
• For those unable to quit completely, harm reduction is essential. E-cigarettes, though not risk-free, are less harmful than traditional cigarettes and may assist with smoking cessation. However, their long-term safety remains uncertain, and FDA-approved treatments should be prioritized. 
• Educate patients on the risks and benefits of e-cigarettes and favor FDA-authorized options when considering alternatives to smoking. 
• Tobacco use disorder should be treated as a chronic disease, with treatment plans tailored to patient preferences and tolerability. Motivational interviewing may enhance adherence and engagement. 
• Quitting is a process that often requires multiple attempts. Encourage progress, learn from setbacks, and celebrate small successes. 
• New therapies like cytisinicline show promise as effective and potentially safer options for smoking cessation. 
• Policy measures such as age restrictions for use, taxation, and marketing controls are critical in reducing smoking and vaping, especially among youth. 
• Free behavioral support programs are available and should be actively recommended to patients during office visits. 

🔗 Resources

• ASAM’s State of the Art On-Demand Session: Nicotine  
• Cytisinicline for Smoking Cessation: A Randomized Clinical Trial: Rigotti NA, Benowitz NL, Prochaska J, et al., JAMA. 2023;330(2):152-160. 
• Electronic Cigarettes for Smoking Cessation - Have We Reached a Tipping Point?: Rigotti NA. N Engl J Med. 2024;390(7):664-665. 
• Treatment of Tobacco Smoking: A Review: Rigotti NA, Kruse GR, Livingstone-Banks J, Hartmann-Boyce J. JAMA. 2022;327(6):566-577.  
• FDA Authorized E-Cigarettes: FDA Authorized Products 
• Web Resource: Smokefree.gov 
• Quitline: 1-800-QUIT-NOW 
• Text Message Program: SmokefreeTXT 
• Youth/Young Adults Text Program: Text DITCHVAPE to 88709  

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