1. Tobacco and the Fight at the Next Level Patrick J. Flaherty, DO, FACC Arkansas Heart Hospital May 2015

2. Smelly statistics 500,000 smoking related deaths 53 M Americans smoke Stopping Reduced CAD by 50% 1y Reduced lung CA 50% 10y Many/most want to quit Why can’t they??

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4. Nicotine Complex physiologic addiction Chemical defense from insects Activation of cholinergic rec Dysfunction of nervous system Nicotinic receptors (as opposed to muscarinic) Present in mammals

5. Nicotine effects Numerous similar to opioids, coke, meth share some physiologic pathways increases dopamine some by blocking uptake some by blocking receptors some genetically at risk

6. What goes on? Antidepressant effect enhance task performance memory and attention transient inc bp and hr

7. WITHDRAWL IS A BITCH irritability sleep disturbances/fatigue bradycardia anxiety/restlessness poor concentration dec rxn time impotence hunger/weight gain depression

8. Smoking cessation pharmacologic/behavioral smoking gets it done effective at delivering drug nicotine lipid soluble crosses rapidly across pulm caps rapid brain peaks leads to reinforcement addiction=peaks withdrawal=steady state

9. Conventional alternatives Patch Gum Inhaler Nasal Spray Chewing tobacco Cigars More cigarettes

10. They can work but…. Approximately doubling quit rates How do you define this? Does one vs. the other help? What about combined therapy? Bupropion active on DA receptors wellbutrin and zyban behavioral therapy

11. CARPE DIEM go after achilles heel cabg mi stroke amputation loss of a spouse from MACE

12. WHAT’S NEXT??? WHAT ARE WE MISSING? ARE WE TOO PROUD?I IS THE ISSUE JUST GOING AWAY? OBAMATAX EFFECT?

15. 2013 Dr. Richard Carmona Former US Surgeon General

16. Reynolds #2

17. Lorillard #3

18. Altria (Phillip Morris)

19. Right up front!!!

20. Full attention

21. Huge money 250-500M market in 2012 Awareness doubling annually 20% US pop are smokers 20% of US smokers e-cig This is climbing fast

23. Next level

24. Economics 101 One 10 ml bottle=$10 180 regular cigarettes Cigarette price per pack $4.96 KY (lowest) 14.50 NY(highest) Entry level vape $50