Time Stamps

  • 04:50 What questions are important to ask after a patient who contemplative about quitting tobacco? 
  • 07:00 Is quitting abruptly on a quit date or gradual cessation to a quit date better?
  • 08:10 How can technology help support patients who are trying to quit?
  • 08:49 How should we prepare patients who quit smoking and are worried about weight gain?
  • 11:06 How can we try to convince patients to use medication as assistance to quit smoking?
  • 11:50 What is the most effective nicotine replacement approach? 
  • 13:54 What are the potential side effects of the nicotine patch?
  • 15:00 What should we prescribe for patients who smoke <5 cigarettes a day?
  • 16:28 How can we determine how severe a patient’s nicotine dependence is?
  • 18:26 When is the ideal frequency of nicotine gum or lozenge?
  • 21:45 How does Varenicline work?
  • 25:05 Can you start Varenicline in patients who have had psychiatric history? 
  • 27:15 What major side effect is seen in patients taking bupropion?
  • 29:15 How do e-cigarettes work?
  • 31:18 How should we approach adding e-cigarettes into a patient’s plan for quitting?
  • 31:42  How should we discuss e-cigarette use with our patients?
  • 33:47 Recap 
  • 39:54 Screening for Barrett’s Esophagus

Show Notes

Pearl 1

Pearl 2

Pearl 3

Pearl 4

Pearl 5 (Throwback for spaced repetition)

  • Indications for screening for Barrett’s Esophagus is men with GERD > 5 years plus two more risk factors: Causasian race, age > 50, any smoking history and family history of BE or esophageal adenocarcinoma.


Pearl 1. Introducing smoking cessation: How can we best set our patients up for success in quitting tobacco?

M: Alright guys, so let’s start with a case.  Mr. Quinton C. Gritts is a 57 year old man with diabetes, hyperlipidemia, and a touch of COPD who is presenting to you to establish care. When you get to the healthy habits part of your history you learn that he has smoked for 35 years at approximately 1-2 packs per day.  It’s at this point in the interview when I usually take a deep breath, look at the clock to see how much time before my next patient (S: Or how much time they’ve now been waiting…) and consider whether to travel down that road. 

S: Part of me is like ain’t nobody got time you are already running 25 mins behind and another part of me is like ugh smoking cessation prolly the most important thing I can help this man do. So I cave and travel down that road

Susan: Right and traveling down the road is worth it – there are different communication models like motivational interviewing or the  5As… bottom line whatever strategy you use, the takeaway is that brief assessments and brief advice do work 

M: And also fun fact, bringing up smoking actually increases patient satisfaction regardless of their ability to quit. Honestly something that I’ve become acutely aware of in the last year of being a full time primary care doc is that when I first meet a patient I’m trying to not annoy them, right, and sometimes I think to myself I met them 10 minutes ago and now I’m supposed to lecture them on something that everyone knows they should stop?  But the data is pretty clear that patients not only expect their docs to address smoking but in fact have higher satisfaction with those who do bring it up.  

S: Alright now that we are concern-free about bringing it up!  Back to Mr. C. Gritts – he’s actually been considering quitting smoking now since he got sick with pneumonia a few years ago. That’s gonna put him in the “contemplative” bucket.  But time is ticking – what’s the highest yield thing to address with him? Let’s make this a game-what questions would you bet on to move him to the preparation stage?

Susan: I’d put my money on celebrating prior successes. I like to set up the convo with asking about prior attempts. I’d ask him “if you’ve been able to quit before? And what worked for you in the past?”

S: Nice, I see what you’re doing there: understanding prior attempts and built up your patient’s confidence. To me the gamechanger info to get in limited amt of time comes from ask  was there any trigger that made you go back to smoking? Dr. Fiore reminded us of a very common and predictable pitfall: 

Michael Fiore: Half of people who try to quit and relapse have their first puff of cigarette smoke with some alcohol in their bloodstream and other smokers in the household are another big challenge and to try to come up with ground rules that support your efforts to quit. 

S: Yep, some of the toughest cases I’ve had were with patients who were quite motivated to quit but lived with other smokers or have had a habit of smoking with alcohol  or their morning coffee. I’m not sure if there are any easy answers here – at least we can try to make a plan for how to respond to those triggers or what to replace the habit with. And it might go something like: 

Scott Sherman: So before, when you went out with friends to a bar and it was difficult for you, what might you do differently this time? Try and resist the urge to tell them because this really needs to be, they need to come up with solutions that work for themselves.

M: Amen! It’s hard for us to not jump in there with solutions but getting the patient to come up with a plan is always the best strategy.  And really during the interview I’m working bit by bit toward getting the patient to commit to set a quit date.  

S: That’s a good one. Sometimes I find myself in situations where I am thinking should I push my patient cold turkey on that OR slowly taper down the amount of cigarettes to that quit date.  

Susan: Well, there’s a study for that! A study in  Annals of Internal Medicine randomized 700 smokers either going cold turkey, or to a  two-week taper prior to a specific quit date. And the winner was: A higher likelihood of quitting in those who stopped abruptly. And to quote numbers: at 4 weeks, 50% quit in the abrupt group vs 39% quit the slow taper group 

M: And at 6 months that difference was still significant! 22% in the abrupt group vs 15.5% in the taper group

S: And it turns out that patient preferences regarding taper vs abrupt quitting is important – in the same study those who prefered gradual cessation at baseline were less likely to quit regardless of the abrupt or gradual cessation group they were randomized to 

M: Interesting, maybe their preferences for gradual cessation may reflect more ambivalence to quitting and might be an indicator to give more help

Susan:  And that’s where technology can help us!

Scott Sherman: If they go to they can sign up for, uh, to get text messages starting before their quit date and after their quit date. And that also doubles your chances of success. So it does what you don’t need to do in your office. It gives them a lot of support to help them quit.

S: I often share computer screen and we fill out the form on or I just have the patient text QUIT to 47848 in the clinic. Technology for the win! 

M: Love this! One thing I mention up front is weight gain because whether or not we ask it is often on my patients’ minds:

Michael Fiore: One thing I always tell my patients who are considering quitting is, uh, to be honest with them about the weight gain challenge. What we know is that the average patient who smokes cigarettes, weighs between five and 10 pounds less than individuals who don’t smoke. And it probably has to do with the effects of nicotine on metabolism as well as the known appetite suppressive effects of nicotine itself. Thus, it’s common, in fact the rule rather than the exception that when people quit smoking, they on average gain between five and 10 pounds. The one treatment that has been shown to mitigate the weight gain is a short acting nicotine replacement therapy including the mini lozenge.

M: What a teaser for the next pearl on NRT! But before we go there, let me try to wrap this section up. After asking about current smoking and assessing readiness to change, we highlighted three high-yield things to cover with patients who are contemplative:

(1) past attempts and what helped them quit, 

(2) what were their triggers that led them back to smoking?  Ask about other smokers in the house and alcohol use as well as reluctance about weight gain, and

(3) try to nail down a quit date

Pearl 2. Nicotine replacement therapies: How do you counsel patients on best use of nicotine replacement therapies and their side effects? 

S: So turns out, Mr. C. Grates has never had any prior attempts at quitting so we don’t know what things have helped him stay away from cigarettes or what things triggered him to go back to smoking but he wants to quit abruptly and wants to quit in 1 week. He is motivated but doesn’t feel like he needs any medication assistance with it. 

Scott Sherman: I get a lot of patients who say, Oh doc, I don’t want to use these medicines. Um, and I point out to them, if you are going to the casino in Atlantic City or Las Vegas and I had something that would double your odds against the house, would you, would you use that? And like, of course, well, why not do it here? Because tobacco companies have spent billions and billions of dollars to make this product as addictive as possible. Why not give yourself every bit of help you can.

Susan: Let’s delve into the 5 types of nicotine replacement therapies -the nicotine patch, lozenge, gum, inhaler and nasal spray.  Spoiler alert – all of these help people quit smoking, so your best bet is to go for whatever the patient is willing to try. Most important thing is prescribing a long  acting and short acting nicotine replacement. I like to teach that we are doing “basal – bolus” but not with insulin, with NRT.

Michael Fiore: This combination of the nicotine patch worn around the clock to give you a baseline degree of nicotine to blunt the withdrawal symptoms that you will experience along with the nicotine lozenge, um, is the most effective nicotine replacement approach to help our patients to quit. 

S: And just how effective? Right so when compared to placebo, looks like the combination or basal-bolus NRT regimen that Susan likes to teach about gives three times the odds of quitting vs. a single form of nicotine replacement is less less than doubles the odds 

M:  Solid – let’s tackle the nicotine patch first.  The dosing options are 21, 14 and 7mg, but I’ve been pretty arbitrary selecting dosing for different patients  … 

Susan: Yep, I’ve seen people just order whatever is easier to click on their EMR.  But to dose the patch correctly you need to know how many cigarettes your patient is smoking every day.  But if they are, and are smoking > 10 cigarettes or half a pack, then start with the highest dose – the 21mg patch.  If < 10 cigarettes, we would start with the 14mg patch. If they smoke <5 cigarettes daily, then we can avoid the patch altogether and use the short acting NRT options.  

S: feel free to go to the Core IM podcast website to look it up show notes or screenshot the infographic. Anything else we should be reviewing when prescribing the patch 

Susan: I think it’s important to tell the patient that there can be skin irritation so try to apply the nicotine patch to a different area everyday. 

S: And what side effects should we tell our patients about?

Susan: Definitely tell them about the possibility of  vivid dreams. About 20% of patients may have vivid dreams 

Scott Sherman: And for most of them it’s not, not nearly enough to get them to stop using it. They just are surprised. So it helps to warn them ahead of time that, uh, if it really bothers them, they can take the nicotine patch off at bedtime and put a new one on in the morning. They’ll have a bit more cravings in the morning, but they won’t have the vivid dreams. And I do remember one patient I was talking to who was in a drug treatment program had been using drugs all his life. And when I counseled him about it and said the vivid dreams, I know I love those things. I can’t wait to get on these. Again. It was not the answer I anticipated, but whatever worked for him.

M: Not sure I love using hallucinations as leverage to quit, but yeah whatever works for our patients.  Next up is the mini lozenge – this was something I knew absolutely nothing about before speaking with Dr. Fiore… and it turns out to be a really effective option – especially for those smoking less than 5 cigarettes per day! (Think bolus). He thought it was really important that we emphasize the new nicotine lozenge, also called the mini lozenge:

Michael Fiore: In terms of an individual who smokes less than five cigarettes per day, we don’t use the nicotine patch. We exclusively use the nicotine lozenge since the mini lozenges and I want to emphasize the importance of prescribing the mini lozenges. And the reason for that is it’s much more palatable for the patient than the original lozenge and juices which are large shocky and cause more gastric distress. So many lozenges is more likely to dissolve in the mouth. It achieves blood levels of nicotine much more rapidly.

S: Who would have thought there would be such major developments in the nicotine lozenge world?  

M: Oh yeah this was like when they started selling pretzels WITH hummus and just [explosion sound] completely revolutionized the way I snack… 

Susan: Yeah, I suppose that’s kind of the same thing… 

M: But the trick to dosing the mini lozenge is that you also need to know a bit more about your patients’ smoking habits, particularly, when their first cigarette of the day is

Michael Fiore: Any of our patients actually get up in the middle of the night to smoke cigarettes and if they’re smoking a cigarette within 30 minutes of awakening, they’re telling us they’re highly a nicotine dependence and probably need more nicotine replacement therapy

M: Exactly – so if  they are smoking within 30 minutes of waking up, then the appropriate dose of the mini-lozenge is 4mg, otherwise it’s 2mg.  

S: Wow I definitely have not been asking my patients when their first cigarette is, add that to the list of Qs from Pearl 1. And what about side effects, Susan?

Susan: Pretty minimal with mini-lozenges. They key is to make sure your patients are not chewing the lozenge – just to place in their mouth and let it dissolve. And you can use up to 20 mini lozenges a day!

S: OH alright, moving on to nicotine chewing gum. Perhaps the most often incorrectly used medication we offer in general medicine…

Susan: Exactly, and contrary to its name, key is to chew the gum as infrequently as possible! [S: we should change its name from gum to a nicotine parker] The nicotine is absorbed through the buccal mucosa so you want to park it between the cheek and teeth until the taste is lost, and at that point it’s time to re-chew, re-up on oral saliva and then repark.  

M: I make the analogy to chewing tobacco most frequently because it’s a visual that almost all patients can relate to.  And avoiding swallowing it is supes important because that big dose of nicotine in your gut will cause the main side effects of nicotine gum – GI irritation.  

M: And in terms of dosing the gum, the same dosing approach applies for nicotine lozenges, right? 

S: Yep – so if patients are having their first cigarette of the day within 30 minutes of waking they should be on 4mg gum dose and 2 mg if first cigarette occurs after 30 mins. But how frequently should patients be using nicotine gum during the day? 

Susan: Its recommended every 1-2 hours but  also whenever there is an urge to smoke. Patients can use up to 24 pieces a day! At first I thought that was a bit excessive, but Dr. Sherman points out this is a common pitfall:

Scott Sherman: If you wait, most people tend to wait until they’re getting a craving and that’s too long to really get the most effect. You should be doing it every hour or two so that even before you get the cravings.

S: Exactly as my patient once humbly told me it takes a little less than a minute for to light a cigarette but def more than a few minutes for NRT to kick in after a craving so my take away is to coach patients to stay ahead of their cravings

Susan: The other hard thing, is to coach them not have soda, coffee or alcohol with their NRT because nicotine needs an  alkaline environment  to get absorbed well, which is pretty difficult to do if you’re parking gum in your cheek every 1 to 2 hours for at least 20 minutes. 

M: Nice, so the gum and lozenges  are similar in terms of dosing and frequency of use  – why might we use lozenge over the gum? 

Scott Sherman: also the gum sticks to dentures, so you need to make sure they don’t have dentures because that will not endear them to you if you’ve ruined their dentures by having them use the gum. 

M: Alright – this has been a beast of a pearl already, but we should round out the NRT discussion with the least-often used modalities: nicotine nasal spray and inhaler.  

Susan: Right,  the nasal spray is the least used because it causes nasal and throat irritation, which many patients find you know, irritating. But a bonus is that it increases nicotine levels faster than any other NRT.  So if they really feel a craving coming on, this might not be such a bad option. 

S: Finally, the nicotine inhaler is meant to mimic the hand-to-mouth ritual that is often so tough to shake. Interestingly – the inhaler is also designed to be absorbed via buccal mucosa so patients should be counseled to puff and don’t inhale

M: anyway let’s wrap up this section.   Best practice is to combine the nicotine patch with another short-acting therapy: either the lozenge, gum, spray or inhaler. Side effects to prep patients about is vivid dreams with all nicotine replacement and skin irritation with the patch so to change up the area every day. With the lozenge and gum, it’s important that its absorbed through the cheek. Dose the 4mg ones if your patient smokes within 30 mins of waking.

Pearl 3. Non-nicotine replacement therapies: Outside of nicotine replacement therapy, what alternative options are available to help our patients quit tobacco? 

Susan: Wait guys, what about Mr. C. grits? Did he quit smoking?

S: So we set that quit date, gave him the right dose patch and lozenge but he had a really stressful day at work and needed that cigarette break. So he comes back a couple weeks later, we talk to him some more and he’s still interested in giving it another shot. 

M: Cue Varenicline aka Chantix! Varencline just about triples your odds of quitting compared to placebo

Michael Fiore: So Chantix is a non nicotine pill. It was built specifically to help patients to quit smoking. And it works at the site of nicotine addiction in the brain by both binding to nicotine receptors, thereby blocking the reinforcing effects of nicotine that come in the, uh, a cigarette, but also by mimicking nicotine and causing the release of dopamine and other neuro receptors that mimic the effects of nicotine on the brain. So it’s both the nicotine agonist and antagonist in that way.

S: Understanding that pathophys may be a good way to counsel patients and believe in the medication – varenicline will both trick your brain into thinking that you’ve just had a cigarette, making you feel satisfied, decreasing cravings while at the same time, blocking that reinforcing reward pathway making cigarettes LESS enjoyable 

M: Exactly, and that latter action – that nicotine blocking ability – is really what separates varenicline from NRT.  So what about risks or side effects to be aware of? 

Susan: Two major side effects are nausea and yet again some vivid dreams.  A ⅓ of patients get nausea that gets better with time, but I do advise my patients to take it with food and water.  About 20% will experience insomnia or vivid dreams – that’s bc varenicline acts as a partial agonist at the nicotine receptor. The work-around for the sleep disturbances is taking the second dose with dinner instead of before bedtime. 

S: Big fan of those work arounds. I hate anything that messes with my sleep. But we still haven’t gone over how we would start someone on varenicline. 

Michael Fiore: You begin taking it one week before the quit date and you worked up but dose, um, and it’s prepackaged this way, 2.5 milligrams per day times three days, 2.5 milligrams per day, bid times four days. That takes you through the first seven days. If on day eight, the patient totally quit, not even a single puff and they increase their dose to one milligram bid each day for you. Continue that for three to six months.

M: Sounds easy enough.  As Dr. Fiore mentioned there are varenicline starter packs which walk patients through the dose increase over the first week in a pretty sweet blue and green blister pack.  

S: so impressed and disturbed you actually know the colors of medication

M: Google is an amazing tool Shrey. And please learn from me if/when your patients asks for a refill make sure to just order the 1mg twice daily instead of the starter pack again… Not gonna lie Shrey – the learning curve as when I was a first year attending rivals that of intern year…

S: Its gets better, its gets better – speaking of getting better, varenicline had a tough start but  now things have cleared up for it 

Susan: Varenicline had a bad name: or in medicine, that means it had a Black Box warning.. during its post-marketing surveillance period there was a disturbing trend of psychiatric issues – particularly suicide and suicidal ideation

S: oh yeah thats right, I do remember being taught at one point to screen patients for SI before starting varenicline… 

M: Yeah, I actually just had a patient ask me about this – she had heard about the ‘mental health’ concerns.  I told her about the EAGLES study which randomized 2,000 people to either varenicline, bupropion (which we’ll get to in a moment), nicotine patch or placebo.  Half of these patients had some stable psychiatric conditions. The study found no difference in psychiatric adverse effects among the different groups and so the black box warning was removed in 2016.  

S: First of all, I love how you are talking to your patients about RCTs and hope that eased her concerns! Curious in the Eagles study, how effective was varenincle compared to the other smoking cessation options? 

Susan: Yeah, so varenicline won the day – it outperformed both bupropion and the nicotine patch with an abstinence rate of 33% after 12 weeks and 21% after 24 weeks.  

M: Ahh nothing like the double-blind, placebo-controlled RCT to vindicate a dubious checkered past.  AND those abstinence rates go up even more when you add combination NRT to varenicline and some experts even advocate just starting patients out combination NRT and varenicline!

S: let’s move on non-NRT pharm section with the other “bupe”… that is bupropion

Susan: Yup, classic teaching is that sustained-release bupropion is another good option, especially if patients have another reason to start this medication like depressed mood. 

S: Great do you start bupropion a week before the quit date as well  similar to varenicline? 

Susan: Yup. Start with one 150mg tablet for the first three days and then ramp up to 150 twice daily starting on day 4. 

M: And what’s the important side effect for bupropion that listeners need to be aware of?

Susan: Seizures! Ok, not really, it does not cause seizures, but it can lower the seizure threshold and is so kinda contraindicated patients who have hx of seizures.  Give patients a heads up on that +/-30% of patients will experience insomnia and <30% will have dry mouth

Scott Sherman: Anxiety is the one that I see the most, maybe in 15% of people. It makes it taking, it makes them anxious. Um, again, in one study I did, only five or 10% said it made them anxious enough to actually switch treatment or stop the drug.

S: Good to know so let’s recap the non-NRT therapies for smoking cessation.  With Varenicline the take-away is that is one of the more effective smoking cessation options, especially when used with nicotine patch and and short-acting NRT.  And despite early reports, it is safe even in patients with a history of psychiatric issues. With bupropion, be cautious in patients with a history of seizure or on medications that lower the seizure threshold.  And best practices with both medications is to start 1 week before quit date.

Pearl 4. Electronic cigarettes: What is the consensus regarding use and efficacy of e-cigarettes in helping our patients quit smoking? 

M: Alright, so at this point we’ve covered the traditional medical therapies for smoking cessation.  Let’s get a little provocative here. Our patient – Mr. C. Gritts – he asks you about your thoughts on vaping.  

S: Mr. C. Gritts wants to be Mr. E Gritts

M: I definitely address e-cigs at least once a week in my clinic… 

Michael Fiore:  There are a few topics in public health over the last year or two that have been in the news more than e-cigarettes. Um, and the reason for that is that they represent really a revolution in changes in terms of the way people deal with nicotine in our society. So for us, what are they? They have basically a system to deliver to the individual nicotine with water and a few other chemicals without the preponderance of chemicals that result from burning a cigarette.

Marty: As shreya mentioned in the intro – we recorded this literally a week before the case reports of vaping associated lung injury starting coming out.  

Shrey:  yeah we back and forth about how to address it with our peer reviewers.  It may be too early to make recommendations from these case reports as investigations are ongoing.  Keep in mind the case reports were mostly adolescents vaping with THC. 

Marty: We do know that the CDC advises to avoid any street-made vaping products and that we should be reporting all cases of new pulmonary disease in the setting of e-cigarette use.   We hope to record separate short episode once there is more data and stronger recommendations for adults using e-cigarettes. 

S: To pivot to efficacy data, the  New England Journal of Medicine published this really well done RCT that authors randomized nearly 900 patients to either electronic cigarettes or NRT.  They were either given an e-cigarette starter pack or literally any NRT of their choice, followed for a year, and guess what happened? Those in the e-cigarette group were almost twice as likely to be abstinent at 1 year compared to the NRT group – quit rates were 18% vs 9.9%.  

M: Yeah, two thumbs up on how pragmatic that study was – letting the control group chose which NRT modality is a great way to compare the decision that I ask patients to make in my clinic all the time.  

Michael Fiore: The first is if the patient is willing to make a quit attempt, use the medications that have been shown to be safe and effective by the FDA. We have a lot of history with them and there are lots of reasons why they should be our first approach. 

M: Okay – that makes sense.  We’ve spent this entire episode talking about 7 FDA approved therapies – 5 NRTs and 2 meds – with really good long-term safety data.  Bottom line – push these options first.

S: And some people would say the higher dose of nicotine in e-cig probably sets up up for higher quit rates and are fine if that’s what they want to choose first.

Michael Fiore:  But if the patient says to us, I really want to try e cigarettes are, I’ve used those and they haven’t been helpful to me, some key additional recommendations need to be made to the patient who’s making this decision first upon beginning a quit attempt, they should totally stop combustible tobacco use because one of the greatest risks of e-cigarette uses for adults is what’s called dual use using e-cigarettes part of the time and combustibles the rest of the time. The majority of Americans who are using cigarettes are dual users not quitters of combustible tobacco use.

M:  If you’re going to vape then vape.  Don’t expose yourself to BOTH the known evils of smoking cigarettes and the great unknown of e-cigarettes.  

Michael Fiore:  The second important advice that I always give patients who make a decision to use e-cigarettes to help them to quit is to use it for a finite period of time rather than to be an e-cigarette user for the rest of their lives. 

M: I love this – first set a date to quit smoking cigarettes and transition to e-cigarettes, and THEN set a quit date to stop all nicotine!!  

S: Quit dates on quit dates on quit dates! Mark up those google calendars!

Susan: For sure!  The importance of setting up your patient to eventually quit e-cigs was actually noted in an accompanying editorial of that New England Journal of Medicine paper. It showed that after one year, 80% of patients in the e-cigarette group were still vaping, while only 9% in the NRT group were still using NRT.  That’s a major difference!  

M: That’s a ton of people still on the vape… Alright so a few big takeaways from the  e-cigarette pearl: first I think this recent outbreak of vaping associated lung injury does affect the shared decision-making conversation.  WE should encourage the 7 types of FDA-approved cessation therapies, but if your patients prefer e-cigarettes, they should really abstain from combustible cigarettes.  Also, it’s important to discuss clear duration of treatment and “off ramp” for stopping e-cigarette use.  

S: And now, we hear from Dr. Scott Sherman doing the recap and adding his own insights into the pearls.

Pearl 5. Throwback pearl – Barrett’s Esophagus: What are the risk factors for Barrett’s esophagus?

M: In thinking about the throwback for this episode and we tried to think about topics we have covered with a meaningful connection to cigarette smoking, and what came to mind is Barrett’s Esophagus

Susan: I don’t see that connection

S: Yeah, so we spent a whole pearl during episode 33 Barrett’s Esophagus discussing who should actually screen. I cheated and had to remind myself of screening guidelines

M: Yep basically to screen MEN with GERD > 5 years plus two more risk factors: Causasian race, age > 50, any smoking history and family history of BE or esophageal adenocarcinoma. 

S: Right that was a really interesting discussion about tailoring who you screen to the HIGHEST risk group for Barretts because it a high cost screening test, an upper endoscopy EGD for a relatively low % who get transformation to adenocarcinoma.

M: that’s right – there was that story about the middle aged fat white guy who brings his wife to the endoscopy suite for her Barrett’s screening EGD and based on likelihood of disease the person who really should be screened is the driver.

Susan: Ahh yes, I remember that now

M: Alright that’s a wrap for us. Thanks everyone for listening!