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To evaluate the relationships between immediate supervisors' leadership qualities and the subsequent levels and changes in burnout and satisfaction of supervised physicians 2 years later.In 2015 and 2017 physicians were asked to complete surveys that included the 9-item Mayo Clinic Leadership Score (range, 9 to 45) assessing their supervisor, an item about satisfaction with the organization, and two items from the Maslach Burnout Inventory. Individual participants' responses to the surveys were linked.Among the 3698 physicians invited to complete both the 2015 and 2017 survey, 1795 (48.5%) responded. The mean composite baseline leadership score was 38.1 (SD, 8.4). Lower mean baseline leadership scores were reported by physicians who had burnout (mean [SD], 36.0 [9.7] vs 39.1 [7.3]; P.001) 2 years later in comparison to those who did not have burnout 2 years later. In multivariable analysis, higher baseline leadership score of supervisors was independently associated with lower odds of physicians having burnout 2 years later (for each 1-point increase, odds ratio, 0.98; 95% CI, 0.96 to 0.99; P=.002) after adjusting for burnout at baseline, age, gender, length of service, and specialty. Baseline composite leadership score of supervisors was also independently associated with physicians' satisfaction with the organization 2 years later (odds ratio, 1.05; 95% CI, 1.03 to 1.07; P.0001).Physicians' ratings of their immediate supervisors' leadership qualities were associated with their subsequent levels and changes in burnout and satisfaction 2 years later. Additional studies are needed to determine the effect of sharing such scores with immediate supervisors and providing additional leadership training to those with low scores, and if doing so ultimately reduces burnout and improves satisfaction of the supervised physicians.

Objective To compare the incidence, severity, and clinical course of frequently reported adverse events (AEs) after treatment with smoking cessation pharmacotherapies. Methods This was a multinational, multicenter, post hoc analysis of frequently reported treatment-emergent AEs from a large, phase 4, double-blind, randomized, triple-dummy, placebo-controlled trial (EAGLES), conducted between November 30, 2011, and January 13, 2015, that included smokers with and without psychiatric disorders (N=8144). Treatments were varenicline 1 mg twice daily, bupropion sustained-release 150 mg twice daily, and nicotine patch 21 mg once daily with tapering (12-week treatment, 12-week nontreatment follow-up), with incidence, time to onset, and duration of frequently reported AEs (≥5% of participants in any treatment group) measured. Risk differences for AEs for varenicline and bupropion vs nicotine patch were compared. Results Across frequently reported AEs, nausea, insomnia, abnormal dreams, anxiety, irritability, dry mouth, fatigue, and application site pruritus differed significantly in active treatment vs placebo groups. Risk differences were as follows: for nausea with varenicline vs nicotine patch, 15.50% (95% CI, 13.20% to 17.80%); for insomnia with bupropion vs nicotine patch, 2.58% (CI, 0.65% to 4.51%); and for abnormal dreams with varenicline and bupropion vs nicotine patch, –2.49% (CI, –4.35% to –0.64%) and –5.60% (CI, –7.27% to –3.93%), respectively. Frequently reported AEs of severe intensity and treatment discontinuation were experienced by less than 1.5% and less than 3% of participants across all groups, respectively. Conclusion Active treatments were well tolerated with comparable AE profiles. Most AEs are not clinically important, and prescribers can reassure patients that those experienced will be manageable. Trial Registration Clinicaltrials.gov Identifier: NCT01456936 .

The use of electronic cigarettes, known as vaping, has become increasingly popular over the past decade, particularly in the adolescent and young adult population, often exposing users to harmful chemicals. Vaping has been associated with a heterogeneous group of pulmonary disease. Recently, a multistate epidemic has emerged surrounding vaping-related acute lung injury, prompting the Centers for Disease Control and Prevention to list an official health advisory. In this review, we describe the current literature on the epidemiology, clinical significance, as well as recommended evaluation and treatment of vaping-related lung injury.

To explore the relationship between immediate supervisor leadership behaviors and burnout and professional satisfaction of health care employees.From October 2 to 20, 2017, we surveyed nonphysician health care employees. The survey included 2 items from the Maslach Burnout Inventory and items on their immediate supervisor leadership behaviors. Logistic regression was performed to evaluate the relationship between the leadership score and the prevalence of burnout and satisfaction after adjusting for age, sex, duration of employment, and job category. Sensitivity analysis was performed using mixed models with a random intercept for work unit to assess the impact of the correlation within work units on burnout and satisfaction with the organization.Of the 57,414 employees surveyed, 39,896 (69.5%) responded and answered the leadership questions. Supervisor scores in each dimension and composite leadership scores correlated with burnout and satisfaction of employees (P.001 for all). In logistic regression, each 1-point increase in leadership score was associated with a 7% decrease in odds of burnout and an 11% increase in odds of satisfaction (P.001 for both) of employees. The mean composite leadership score rating of each immediate supervisor correlated with rate of burnout (r=-0.247; P.001) and the satisfaction with the organization (r=0.416; P.001) at the work unit level.Leadership qualities of immediate supervisors relate to burnout and satisfaction of nonphysician health care employees working in a large organization. Further studies are needed to determine whether strategies to monitor and improve supervisor leadership scores result in reduction in burnout and improved satisfaction among health care employees.

Given the high morbidity and mortality and the large societal burden imposed by cardiovascular (CV) disease, there have been many strong interdisciplinary efforts to identify at-risk patients during the past decades. The Framingham study and other population-based studies of CV risk, outcomes, and the effect of therapeutic interventions on both have identified what are now considered the “traditional” modifiable CV risk factors, such as hypertension, hyperlipidemia, diabetes mellitus, smoking, obesity, and sedentary lifestyle. However, approximately one-third of CV events are not readily attributed to these traditional CV risk factors.1,2 This finding, often called the detection gap, suggests that other nontraditional or “novel” conditions may cause or contribute to CV disease. At the same time, the trend toward lower definition thresholds for traditional CV risk factors (eg, the change in criteria for what constitutes “low” protective high-density lipoprotein levels, from previously less than 0.91 mmol/L (

Thromboangiitis obliterans (TAO), or Buerger's disease, is an inflammatory, occlusive, and nonatherosclerotic vascular disease that most commonly affects small and medium-sized arteries and veins. The association between tobacco use and the development of TAO is incontestable; however, a substantial number of patients with TAO continue to use tobacco despite progression of disease and amputation. Herein we describe a patient with advanced TAO whose severe, refractory nicotine dependence was successfully treated in a specialized nicotine-dependence inpatient program. After cessation of smoking, the patient's disease stabilized. Inpatient nicotine-dependence treatment may represent an alternative for recidivist smokers with severe tobacco-related disease.

To compare the effectiveness of outpatient vs residential treatment for tobacco dependence in a large referral practice.We analyzed data from 2 cohorts of cigarette smokers who received either comprehensive outpatient or intensive 8-day residential treatment for tobacco dependence between January 1, 2004, and December 31, 2007. Self-reported 7-day point prevalence abstinence from smoking at 6 months was obtained via telephone interview. Logistic regression was used to assess the likelihood of increased abstinence with residential treatment.Overall, 4327 cigarette smokers received comprehensive outpatient treatment for tobacco dependence, and 226 smokers received treatment in an intensive 8-day residential program. Compared with outpatients, residential patients smoked more cigarettes per day (mean ± SD, 31.1 ± 14.4 vs 21.2 ± 11.2), had more severe nicotine dependence (Fagerström Test for Nicotine Dependence score, 6.9 ± 2.0 vs 5.1 ± 2.3), and were more likely to have been treated for alcoholism (58/222 [26%] vs 649/4327 [15%]) or depression (124/222 [56%] vs 1817/4327 [42%]; P.001 for all comparisons). The 6-month smoking abstinence rate was significantly higher for residential patients compared with outpatients (115/222 [52%] vs 1168/4327 [27%]; unadjusted odds ratio, 3.0; 95% confidence interval, 2.3-3.9), with similar findings after adjusting for baseline characteristics (adjusted odds ratio, 3.58; 95% confidence interval, 2.6-4.9).Compared with smokers who received outpatient treatment, those who received residential treatment had more severe tobacco dependence. Residential treatment for tobacco dependence was associated with a significantly greater odds of 6-month smoking abstinence compared with outpatient treatment among smokers in a referral clinic setting.

Cigarette smoking is the most important preventable cause of morbidity, mortality, and excess health care costs in the United States. From 2000 through 2004, cigarette smoking caused an estimated annual average of 443,595 deaths and cost $193 billion per year in smoking-attributable productivity losses and smoking-related health care expenditures. Preventing smoking and providing effective treatment to help smokers quit will remain a public health priority for the foreseeable future. In support of this goal, the US Department of Health and Human Services recently published the clinical practice guideline entitled Treating Tobacco Use and Dependence: 2008 Update. The new guideline updates the previous guidelines published in 1996 and 2000 and presents many new research findings to provide a broader evidence base for effective intervention. This article briefly reviews the major updates and recommendations from the new guideline and highlights its practical clinical applications.

Cigarette smoking continues to cause substantial death and disability, but more than 1 in 5 adults smoke despite the desire among most smokers to stop and the availability of effective treatments. A systematic process to identify all smokers is crucial. Because tobacco dependence is characterized by relapses and remissions, clinicians should be ready to engage smokers and reengage relapsed smokers with options for new medication strategies and additional counseling resources.

To determine the relationship between white blood cell (WBC) Indices and several baseline variables In a large cohort of healthy smokers and to assess whether these changed after biochemically confirmed smoking cessation.The study consisted of 784 healthy smokers enrolled in a trial of sustained-release bupropion, 300 mg/d, for relapse prevention after smoking cessation from 1995 to 1998. Both WBC counts and absolute neutrophil counts (ANCs) were measured at baseline, week 7, and week 52. Smoking status was assessed at weeks 7 and 52 by self-report and biochemically confirmed with expired air carbon monoxide levels. Multivariate analyses compared changes in WBC count and ANC between smokers who did and did not stop smoking, adjusting for treatment group, age, sex, and body mass index.Of 784 smokers enrolled, 461 had biochemically confirmed tobacco abstinence after 7 weeks of bupropion; 429 were randomly assigned to receive continued bupropion therapy or placebo until week 52. Between baseline and week 7, there was a significantly larger decrease in WBC count in continuously abstinent subjects compared with continuing smokers (adjusted P = .03). At 52 weeks, continuously abstinent subjects, compared with continuing smokers, had a greater decline from baseline in WBC count (1.2 +/- 1.9 x 10(9)/L vs 0.1 +/- 1.9 x 10(9)/L; P.001) and ANC (1.0 +/- 1.6 x 10(9)/L vs 0.2 +/- 1.5 x 10(9)/L; P.001).Biochemically confirmed tobacco abstinence leads to a rapid and sustained decrease in WBC and ANC, possibly reflecting a decrease In an underlying state of tobacco-induced inflammation.

To compare smoking abstinence outcomes between smokers treated in a residential (inpatient) program and those treated in an outpatient program to determine if residential treatment was superior to outpatient treatment in smokers with moderate to severe nicotine dependence.Patients treated in the residential nicotine dependence program at the Mayo Clinic, Rochester, Minn., between May 1, 1992, and January 31, 1996, were selected for this study. Each patient in the residential treatment group (n=146) was matched to 2 patients who received an outpatient nicotine dependence consultation by a trained counselor (n=292). Each patient was matched on age, sex, year seen, number of cigarettes smoked per day, longest previous abstinence, education, and marital status. Abstinence at 6 and 12 months was determined by self-report. For the purposes of analysis, each patient with missing outcome data was considered to be smoking.The 6-month abstinence rates for the residential group compared with the outpatient group were 45% and 26%, respectively (P.001), and the 12-month abstinence rates were 45% and 23%, respectively (P.001). After adjusting for matching variables that were not exactly matched (age, baseline number of cigarettes smoked per day, and longest previous abstinence) and the baseline variables, including education, age when started smoking, and degree of nicotine dependence, there was a significant effect of residential treatment on 6- and 12-month abstinence rates (P.001). Odds ratio of 6-month abstinence in the residential group was 2.74 (95% confidence interval, 1.60-4.71; P.001) and at 12 months was 3.03 (95% confidence interval, 1.74-5.27; P.001).Residential treatment for tobacco dependence is superior to outpatient treatment in some smokers who are moderately to severely nicotine dependent.

We thank Dr Cobb for his comments regarding our article. He is correct that smokers have many comorbid psychiatric conditions,1 particularly anxiety, depression, and other substance use disorders. Approximately 40% of patients in our residential program have 1 or more of these diagnoses. We do not target treatment at these conditions, but we do desire comorbid mental health problems to be under good control before we admit patients to our program. It is unclear how much tobacco dependence arises from self-medication of psychiatric symptoms vs a common predisposition to both tobacco dependence and a mood or anxiety disorder. Similarly, comorbid medical conditions are determined to be stable through a telephone screening process before we admit a patient to our program. Treating tobacco dependence effectively in any setting is difficult, if not impossible, if a comorbid psychiatric or medical condition is poorly controlled. Few published data are available on how best to treat comorbid tobacco dependence and adult attention deficit hyperactivity disorder. We were involved in one small trial using methylphenidate for treatment of tobacco dependence in patients with established adult attention deficit hyperactivity disorder, and the results (yet unpublished) were disappointing.