From the Editor

He could barely get out of bed because his depression was so severe. Yet he asked to be discharged because he wanted to smoke.

So often our patients struggle with their tobacco use disorder. But what medications have the most evidence? Do apps help? What should a clinician say during a brief encounter? This week, we consider a new paper written by Dr. Peter Selby and Laurie Zawertailo (both of the University of Toronto), just published in The New England Journal of Medicine. The authors summarize the latest in the literature, offering a relevant review that provides answers to these and other questions. And they note the devastation caused by tobacco use: “The risk of lung cancer is 25 times as high and the risk of coronary heart disease or stroke is 2 to 4 times as high among smokers as among nonsmokers.” We summarize the paper and mull its clinical implications.

And in the other selection, Dr. Lisa S. Rotenstein (of Harvard University) and her co-authors think about well-being and burnout in a JAMA paper. In recent years, this topic has gathered more and more attention. That said, Dr. Rotenstein and her co-authors don’t focus on physicians and nurses, as many authors have, but consider other health care workers. They argue: “The everyday functioning of the health care system depends on hundreds of role types. Leaders must seek to address obstacles and causes of work-related frustration not only for physicians and nurses, but also for the home health care workers, nurses’ aides, respiratory therapists, and many others who serve patients every day.” 


Selection 1: “Tobacco Addiction”

Peter Selby and Laurie Zawertailo

The New England Journal of Medicine, 28 July 2022

Tobacco addiction is a treatable chronic relapsing disorder that is characterized by cravings and compulsive use. An estimated 47.1 million U.S. adults (19.0% of the population) currently use tobacco, mostly in the form of cigarettes (12.5% of the population). More than 480,000 adults in the United States die annually from the effects of cigarette smoking, and approximately 16 million have a smoking-related illness. The prevalence of smoking is highest among adults 25 to 64 years of age, and smoking is more common in the following groups than among their various counterparts: persons of color; those with low incomes or low levels of education; those who are divorced, separated, or widowed; those who are non-cisgender or nonheterosexual; those who receive Medicaid, disability benefits, or are uninsured; and those who have anxiety or depression. In the United States, the incidence of smoking among persons with any mental illness is two to four times as high as that of the general population.

So notes Dr. Selby and Zawertailo.

The paper opens with a case:

“A 58-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, hypertension, and a history of major depression that is currently in remission presents with a 45-pack-year history of smoking. She smokes 25 cigarettes per day, with her first cigarette smoked within 5 minutes after waking. She has been unable to quit smoking with the regular use of nicotine gum for 4 weeks. Her current medications include fluticasone–salmeterol, ramipril, metformin, empagliflozin, venlafaxine, and, as needed, albuterol.”

The authors note risk factors for onset of smoking and tobacco addiction, including genetic and environmental factors.

They forward “five evidence-based steps that are effective both individually and collectively.” That is, “screening, clear advice to quit, medication or behavioral support (or both) matched to the readiness of the patient to make a quit attempt, appropriate referral to additional support, and follow-up.”

On counseling and behavioural approaches

“Brief behavioral interventions, such as encouraging a smoker to set a quit date within 30 days, increase cessation rates. In addition, there is a clear dose–response relationship between the intensity of the intervention and its effectiveness in sustaining abstinence from smoking, especially in persons who are not using cessation medications. There is high-certainty evidence that individual counseling spread over several sessions increases quit rates as compared with usual care and brief advice, and high-intensity counseling (i.e., greater length and number of treatment sessions) increases sustained abstinence as compared with low-intensity counseling. Depending on the available resources, counseling may be provided by trained counselors in person or by means of state or national telephone quitlines. Telephone counseling can increase the likelihood of successful cessation, irrespective of the smoker’s degree of motivation to quit.”

They add:

  • “Text-messaging programs also have been shown, with moderate-certainty evidence, to improve quit rates.”
  • “Financial incentives to stop smoking also increase the odds of quitting as compared with minimal intervention.”
  • “Adjunctive approaches include advice to make the home and work environments smoke-free spaces; the use of self-help booklets, Web sites, and smartphone applications (apps); and the enlistment of social support during the quitting process.”

On medications

“Both varenicline and a combination of nicotine patches with short-acting nicotine-replacement therapy are considered the most effective and safe first-line treatments for smoking cessation.”

They add: “Nicotine-replacement therapy is usually started on the patient’s target quit date (the date that the patient commits to abstaining from smoking for at least 24 hours), whereas non-nicotine oral medications are started at least 1 week before. The duration of therapy is usually 8 to 12 weeks; even though most smokers who have a response to nicotine-replacement therapy will quit smoking within 4 weeks after starting treatment, completion of the treatment regimen is associated with a higher incidence of long-term remission. The addition of counseling to pharmacotherapy increases the likelihood of cessation.”

In terms of the evidence:

  • “Meta-analyses of randomized trials have shown that varenicline, a partial nicotine receptor agonist, more than doubles the likelihood of sustained quitting in the general population of smokers when administered at standard or reduced doses.”
  • “Systematic reviews of randomized, controlled trials have shown that all forms of nicotine-replacement therapy that deliver nicotine without the products of combustion (i.e., nicotine patches, gums, lozenges, inhalers, and nasal spray) increase the likelihood of sustained quitting by 50 to 60%.”
  • “Sustained-release bupropion (at a dose of 150 mg administered orally twice daily), through an unproven mechanism of action, increases the likelihood of quitting by 52 to 71% independent of its effect on clinical depression.”

The paper ends by returning to the case:

“She should be educated about the risks of continued smoking (e.g., exacerbations and worsening of chronic obstructive pulmonary disease, microvascular and macrovascular complications from diabetes and hypertension, and smoking-related cancers) and the benefits of smoking cessation. We would recommend either varenicline or combination nicotine-replacement therapy as a first-line treatment, given their similar efficacy and good safety profiles in patients with stable mental health status; the choice should be guided by patient preference and past response had by the patient to either medication.” After four weeks, they suggest “combining varenicline with a nicotine patch or with bupropion.” They add: “If bupropion is prescribed, the patient’s venlafaxine dose might need to be reduced to prevent a drug interaction.” What else to be done? “We would recommend against the use of e-cigarettes for smoking cessation given insufficient evidence to support their use.” (!) They do recommend counseling.

A few thoughts:

1. This paper is excellent – clear, lucid, relevant.

2. The five evidence-based steps are solid. But how many tobacco users receive all five?

3. Advice for the busy clinician? They offer the following: “In a pragmatic approach regarding patients who want to quit, busy clinicians may provide very brief advice, prescribe and encourage adherence to medications, or refer the patients to a smoking-cessation program or quitline (or all these strategies).”

And those who aren’t sure that they do? “For other patients, clinicians can use the therapeutic alliance that they have with a patient to enhance the patient’s readiness to make a quit attempt by regularly expressing concern, recommending cessation, and offering medication to quit and a referral to counseling.”

4. The paper doesn’t focus on those with mental disorders. For the patients we see, tobacco is particularly problematic – they smoke and use tobacco far more than the general population and often are more challenging to engage in treatment. Unfortunately, smoking is so common with those with chronic, persistent mental disorders that tobacco use disorder can be overlooked – yet, it’s a major reason that life expectancy for this population is so much lower than the general population. So… returning to the question in point 2: how many tobacco users with mental disorders receive all five?

5. Smoking cessation has been considered in past Readings, including the concept of the nudge. See:

The full NEJM paper can be found here:

Selection 2: “Addressing Well-being Throughout the Health Care Workforce: The Next Imperative” 

Lisa S. Rotenstein, Donald M. Berwick, Christine K. Cassel 

JAMA, 18 July 2022  Online First 

Much of the clinician well-being movement has focused on physicians and nurses. But as the May 2022 Surgeon General’s Advisory Addressing Health Worker Burnout and ongoing deliberations of the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience highlight, the coronavirus pandemic has underscored the need to attend to the well-being of the entire health care workforce, including nursing assistants, transport personnel, clerical staff, and others. 

So begins a paper by Rotenstein et al.

“In a survey of 10 284 primary care health care personnel conducted before the pandemic, 19.4% of nonphysician clinical staff reported burnout.” They argue that “the pandemic has magnified the problem.” The authors note: 

  • “In a nationwide survey of 125 717 health care workers, the highest turnover rates among all health care workers during the beginning of the pandemic (April 2020 to December 2020) were reported by health care aides and assistants, technicians, and licensed practical and vocational nurses.” 
  • “Ominously, a recent report based on international surveys that also included 434 US clinicians suggested that 47% of the current US health care workforce plan to leave their current role within the next 2 to 3 years.” 

They make several suggestions; we summarize three here: 

The will to act is required.

“[A] vivid understanding of the experiences of nonphysician and nonnurse colleagues can help catalyze the will to improve the nation’s well-being efforts. This may initially be uncomfortable because confronting drivers of well-being across the health care workforce will force examination of manifestations and the consequences of medical hierarchy and inequity. Importantly, nonphysician and nonnurse colleagues must be detailing the barriers they face and suggest potential solutions, rather than having others speak for them.” 

Measurement is central.

“Ideally, some measurements of well-being would be based on self-reports, while others would be derived in more automated ways. Established employee engagement metrics, such as those offered by consulting firms, are one option. These metrics have been tied to others of importance to health care systems, including ratings of the culture of safety. To minimize the additional work associated with new measurement processes, leaders can look with a new lens at the data they already have available. These might include information on turnover, retention, longevity, individuals’ growth within an organization, or time that individuals spend interacting with electronic systems vs time with patients.” 

Effectively addressing the well-being of the entire workforce.

“Much of the common approach to enhancing well-being by addressing organizational determinants has centered on shifting work, for example, by shifting documentation from physicians to scribes or shifting in-basket responsibilities from physicians to physician assistants or nurse practitioners. What relieves some members of the health care workforce may increase workload and expectations for others. More comprehensive, innovative approaches to the design of work may be better for all, such as leaning on technology and systems engineers to ensure that the joy of all parties is considered and the collective workload is reduced. This may mean that documentation requirements are lessened or automated rather than being shifted among health care team members or that chatbots help answer and direct patient queries prior to their reaching nonphysician team members.”

They conclude:

“As the nation and health care system slowly emerge from the coronavirus pandemic with gratitude to the health care workforce for its sacrifices, the time is ripe to address well-being through a wider lens.”

A few thoughts:

1. This is a thoughtful paper.

2. It offers a different take on the issue – not focused on nurses or physicians. Is that perspective overdue?

3. Burnout is a topic covered previously in the Readings. In July, we considered the NEJM paper by the US Surgeon General, Dr. Vivek H. Murthy, which can be found here:

The full JAMA paper can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.