Smoking and Vaping in 2022: Women Leaders in Medicine, Ep. 12

​​​​​​In this podcast, Jaspal Singh, MD, MHA, MHS, interviews Hasmeena Kathuria, MD, and Jill Ohar, MD, on smoking and vaping in 2022, including the effects of the COVID-19 pandemic on smoking cessation, and the prevalence of smoking among youth and adults in the United States and worldwide.

Additional Resources:

• Siegel DA, Jatlaoui TC, Koumans EH, et al; Lung Injury Response Clinical Working Group; Lung Injury Response Epidemiology/Surveillance Group. Update: interim guidance for health care providers evaluating and caring for patients with suspected e-cigarette, or vaping, product use associated lung injury - United States, October 2019. MMWR Morb Mortal Wkly Rep. 2019;68(41):919-927. https://doi.org/10.15585/mmwr.mm6841e3
• Evans ME, Twentyman E, Click ES, et al; Lung Injury Response Clinical Task Force; Lung Injury Response Clinical Working Group. Update: interim guidance for health care professionals evaluating and caring for patients with suspected e-cigarette, or vaping, product use-associated lung injury and for reducing the risk for rehospitalization and death following hospital discharge - United States, December 2019. MMWR Morb Mortal Wkly Rep. 2020;68(5152):1189-1194. https://doi.org/10.15585/mmwr.mm685152e2 
• Leone FT, Evers-Casey S, Graden S, Schnoll R. Behavioral economic insights into physician tobacco treatment decision-making. Ann Am Thorac Soc. 2015;12(3):364-9. https://doi.org/10.1513/annalsats.201410-467bc 
• Folan P, Spatarella A, Jacobsen D, Farber H, Moazed F. Vaping/e-cigarettes. Amer J Respir Crit Care Med. 2015;192:5-6. https://www.thoracic.org/patients/patient-resources/resources/vaping-electronic-nicotine-delivery-systems.pdfelivery-systems.pdf

Hasmeena Kathuria, MD, is a pulmonary, critical care, and sleep physician. She’s also an associate professor of medicine at Boston University School of Medicine, the director of the Tobacco Treatment Center at Boston Medical Center, and the vice chair of the Tobacco Action Committee for The American Thoracic Society. She’s based in Boston, MA.

Jill Ohar, MD, professor of medicine in pulmonary and critical care at Wake Forest University in Winston-Salem, Carolina.

Jaspal Singh, MD, MHA, MHS, is medical director of pulmonary oncology and critical care education, as well as a professor of medicine, at Atrium Health in Charlotte, North Carolina.

Transcription:

Moderator: Hello everyone and welcome to Women Leaders in Medicine, a special podcast series led by our section editor on pulmonary and critical care medicine, Dr Jaspal Singh. The views of the speakers are their own and do not reflect the views of their respective institutions.

Jaspal Singh, MD:

Welcome, everybody. Again, I'm Jaspal Singh. I'm a pulmonary and critical care physician in Charlotte, North Carolina. And today on Consultant360, I would like to welcome 2new guests for our women in medicine series of leaders in pulmonary and critical care, Doctors Kathuria and Dr  Ohar. Dr Kathuria, would you introduce yourself, please?

Hasmeena Kathuria, MD:

Sure. I am an associate professor of medicine at Boston University School of Medicine. I'm a pulmonary, critical care, and sleep physician, and I direct the tobacco treatment center. I do a lot of advocacy work. I'm the vice chair of the tobacco action committee for the American Thoracic Society.

Jaspal Singh, MD:

That's fantastic. Dr. Ohar?

Jill Ohar, MD:

I'm Jill Ohar. I'm a professor of medicine at Wake Forest University. I work in the division of pulmonary and critical care, and I have an interest in COPD. So that's my reason for being here.

Jaspal Singh, MD:

Yeah. And actually, I saw you a long time ago, speak to a bunch of us young fellows about smoking cessation way back in the day. So I've seen you deliver a phenomenal talk on this topic. So I know this is something also very near and dear to you. Well, thank you.

Well, so a lot's happening in the smoking epidemiology, the prevalence, the patterns, including things like e-cigarettes and nicotine products that are coming out of the woodwork. Talk to us a little bit about what key observation you both are seeing, and I'll start with you, Dr. Ohar.

Jill Ohar, MD:

Well, certainly I'm reading a lot about that. I see that, in our youth, in my own practice, which is mostly older patients who have COPD, most of them continue to cling to the old cigarette, they're tried and true or their standby. Now a lot of that may be related to the fact that we live in North Carolina, where cigarette taxes are incredibly inexpensive, and therefore compared to places like in the Northeast, where cigarettes can be as much as $10 a pack, here in North Carolina cigarettes are a buck and change. So some of these new products, most of my patients can't afford and would rather just use a cigarette.

Jaspal Singh, MD:

Interesting. Dr. Kathuria, talk to us a little about what you're seeing.

Hasmeena Kathuria, MD,:

So here in Massachusetts, exactly that, the pack of cigarettes is about $10. We do see some of our patients use little cigars, so I work at a large safety-net hospital, and so the cost can be prohibitive, but people find their way of smoking. So for instance, at our hospital, about 25% of individuals still smoke cigarettes compared to 14% nationally. We are seeing dual product use, which is concerning, mostly cigarettes along with e-cigarettes with the added toxicity of both products. That's concerning. And then of course in our youth, we are seeing e-cigarettes across Massachusetts.

Jaspal Singh, MD:

It's been interesting with the pandemic. I think a lot of the things that were non-COVID related seemed to fit, seemed to get less attention. What are you seeing from the prevalence of e-cigarettes and youth and especially tobacco cessation, the saying that recent pandemic of things that we should be aware of as clinicians in the front line?

Hasmeena Kathuria, MD,:

So, we try to incorporate teachable moments whenever we run our program. So, talking about the risk of cigarettes on immune suppression, the risk of COVID in terms of that, and try to cater our tobacco cessation and counseling to that. So we are seeing that some people are more aware of smoking within the pandemic and want to stop, but we're also seeing a lot of people at home, more bored and increasing use. So we're kind of seeing both patterns.

Jaspal Singh, MD:

Interesting, and what's happening around the globe? Is it cigarette smoking going up, is it going down? Is this something that we need to worry about? Are nicotine products or different types coming about? Just talk to me a little bit about that, if you don't mind.

Hasmeena Kathuria, MD,:

So I would say globally where, at least in the US, we're at 14%, where patients that I see where there's a lot of tobacco-related disparities, where we're seeing very high smoking use. So the 25%, we've looked at data over the years, has pretty much stayed the same. So I'm not seeing a decrease within the pandemic. And I think the disparity is of black Americans and Hispanics. We have a large population that uses opiates. And so with opiate use disorder, we're seeing about 80% of people smoking. And so lots of concerns in certain communities. And we're really trying to work, to target that population, to increase awareness, to decrease some of the disparities and care that we see.

Jaspal Singh, MD:

That's really interesting.

Jill Ohar, MD:

I'm thinking also that it's important at this point to talk about the fact that nicotine, regardless of the product that's being used, whether it's an e-cigarette or a hookah or a regular cigarette, that nicotine is an important gateway drug and enhances youth's susceptibility to other products like the opiates. And I think that kids have been lured into the use of e-cigarettes by the flavoring, et cetera, in much the way that children in the fifties were lured into regular cigarettes. And I think that it's important for clinicians, especially clinicians that take care of young populations, for pediatricians to be aware of this and to ask at every visit, and also to arm children with the knowledge that they're being lured into a habit that will clearly truncate their life, and provide terrible morbidity, as they age.

Jaspal Singh, MD:

That's a great point. The idea of a gateway drug, the idea of, Dr. Kathuria Was saying earlier, that there are multiple substances at once and there's the issue of disparities. What are you seeing, Dr. Ohar, in your population, in terms of e-cigarette usage potentially aimed at quitting, as a mechanism by which to quit or stop tobacco products altogether? Are you seeing that a lot? I thought there was a trend for a while but just haven't noticed as much.

Jill Ohar, MD:

I agree. I think you and I, both being in North Carolina, see pretty similar populations. And again, an e-cigarette is a little more expensive way to get your nicotine. The data on e-cigarettes are that they at least get you off real cigarettes, with some increased potential over a nicotine patch, but you're still using nicotine. And there's a lot of potential harm there, in that it's not only the nicotine, but if you alter the device, if you use the solutions that are often not mainstream cigarette or e-cigarette solutions, you run the risk of vaping associated lung disease. And so I think that it's certainly not a panacea and it probably provides really marginal improvement in terms of smoking cessation.

Jaspal Singh, MD:

Yeah, absolutely. So I think we're all seeing similar patterns and similar issues, but yet it's interesting how the FDA suddenly, in the last year, finally got involved with some of the e-cigarette work and regulation, and that's being paid a lot of attention. There's a lot of confusion out there. I was wondering if either of you could help us clarify what exactly the FDA's doing in this space, what needs to be done, where are they in this whole fight against nicotine products?

Hasmeena Kathuria, MD:

Sure. I can start with that. I spend a lot of time advocating, working with the FDA in regulating these products. So just for some background, in 2009 there was a signing of the family smoking prevention and tobacco control act. We call it the tobacco control act of 2009. And that law, for the first time, established the FDA authority to regulate the manufacturer, the marketing, and distribution of tobacco products. So amazingly before that, tobacco products were largely exempt from regulation under the federal health and safety laws. And then in 2016, that original act really was for cigarettes and smokeless tobacco products, those were the most commonly used products at that time. And in 2016, the FDA now has the authority to regulate all tobacco products. And within that is e-cigarettes, is hookahs, is cigars, so that's where we started to see a lot more authority of the FDA to do this.

So the problem is, has the FDA exerted that authority to regulate these products? And that's where you're seeing a lot of suits against the FDA, to use that authority to regulate e-cigarettes. And so there are really two things that I think are most important. So the first is, tobacco manufacturers are required to obtain an order from FDA, prior to marketing a new product. So in order for a product to be on the market, FDA has to approve that product, that it's appropriate for the protection of public health. So that's where a lot of the debate has come. And so now in 2020, in September, all e-cigarette manufacturers had to file, what's called a PMTA, this pre-market tobacco review, so that the FDA could look at that and then make a decision about whether these products could stay on the market.

And so the FDA is busy trying to do that. They were supposed to do this by 2021, September 2021, but you can imagine there are so many products, and they've made decisions on a lot of them, but not on the big products like JUUL, like Puff Bar. And so what we're hoping is that the FDA says that any flavored e-cigarette products don't protect public health. So that's what we're hoping for, so that all flavored e-cigarettes, under this rule, under this authority, will be taken off the market. So that's the first one that they're spending a lot of time on, and that we're really working on.

The second is, what we're beginning to see, and you had asked as well about other products, we're seeing synthetic nicotine being used. So Puff Bar uses synthetic nicotine instead of nicotine from tobacco. And so the FDA has authority to rule on any tobacco-related products, but not synthetic nicotine. And so they're using this loophole to get synthetic nicotine on the market, and that is really alarming. So we're hoping that the FDA uses authority to really ban synthetic nicotine, to regulate these synthetic nicotine products.

Jaspal Singh, MD:

Oh, that is fascinating. I had no idea about the synthetic nicotine being put on the side there as a bypass, almost, what you're saying, for the FDA. So basically when I used to drive down the street, I see all these hookah bars and all that stuff. Is all that regulated now by the FDA theoretically? Or is that just not being acted on?

Hasmeena Kathuria, MD:

Yes. So that's under the purview of the FDA. So hookah, cigars, not premium cigars, there's a lot of debate on that, but any product that's derived from tobacco can be regulated by the FDA.

Jill Ohar, MD:

It's really fascinating. I think it's made an impact because I know that for me, we saw a lot of acute lung injury due to vaping, for a brief period of time. And then it seemed to disappear as soon as it began. And one would believe that these offline, online, black market kind of manufacturers probably, when the FDA started to exercise oversight, probably went out of business. They just didn't have the legal counsel, the deep legal bench, to fight that kind of oversight. And it's very impressive, the kind of clinical effect it's had, because I don't think I've seen vaping-related lung disease for a couple of years now. And maybe even three.

Jaspal Singh, MD:

I would add, we haven't really seen it much in the last couple of years either, but I wonder if we haven't looked for it because of COVID.

Hasmeena Kathuria, MD:

I think that's part of the problem. We're probably seeing about 10% that's related to nicotine. States aren't required to report EVALI cases anymore, but states that do, that are still collecting that data, they're not using the THC, but it's thought that probably about 10% are related to nicotine-related products.

Jaspal Singh, MD:

Interesting. And so that's a very nice summary of the issues to date so far. I will say though, that my daughters tell me that vaping is present in their population, a fair amount. And so we're still not seeing, I was kind of hoping that what Dr Ohar's getting at, was that a lot of public support for curtailing e-cigarettes still seems to be going as this undercurrent at the schools, in that population. And what's going on there?

Hasmeena Kathuria, MD:

I would say absolutely. Even now, among middle and high school students, there are over four million people that report tobacco product use and about three million that use e-cigarettes. It is a major problem. And so we're really hoping that the flavoring bans will help that situation. Like you had mentioned earlier, the flavors, Dr. Hart, is what the appeal is to kids and youth. And so that's something that's really important in Massachusetts. We have a complete flavoring ban on all tobacco products, so not only e-cigarettes but cigarettes as well, including menthol products. And so we know, if you ban some flavors, kids are going to gravitate to others. So you banned the candy and the fruity flavors we saw an increase in menthol e-cigarette use. So I think that that's the last really, really important FDA regulation that we're hoping for.

Hasmeena Kathuria, MD:

So when I think about our tobacco control policy for this upcoming year, it's the flavoring regulations, and it's also the Biden administration is working towards doing a complete menthol ban on cigarettes, nationwide. We know menthol products are used by black Americans, about 80%, 80 to 90% of black Americans smoke menthol products, due to unfair targeting to that community. We know that menthol cigarettes aren't safe, they increase addiction. And so there's been some really bold movement there to ban all menthol cigarettes. And we're hoping to see a decision in April of this year on the menthol ban.

Jaspal Singh, MD:

Well, that's good.

Jill Ohar, MD:

Again, it's important to know that menthol acts as, as almost a topical anesthetic. And so again, that's another issue of the gateway, where many, many smokers start their addiction through menthol cigarettes or menthol-related vaping. And so it's not the taste of the menthol so much as a flavoring, that makes it easier to tolerate the irritant effects of vaping or smoking. And so I think, again, that's something that's really important for people to understand, especially legislators who are making these important decisions.

Jaspal Singh, MD:

Yeah, that's great. That's a great summary of the issues. I think what I hear is, a lot of still work to be done, and hopefully good luck on that with the ATS and other societies, hopefully pitching in to really take on this next phase of the battle.

Jill Ohar, MD:

I’m wondering how much the COVID epidemic and kids being out of school, has affected trends and uses in kids for e-cigarettes or any kind of nicotine-related product.

Hasmeena Kathuria, MD:

Yeah, that's a great question. Part of the problem is, the surveys that we rely on, the youth surveys, they haven't been done in the same way. So they're trying to do some online, rather than part of their school. So really collecting that data has been challenging. I know in the town that I live in, we're trying to do a lot of work to gather that type of data, and just talking to my teenagers and, similar to what Jaspal said, it seems that it has not decreased. They're at home more. For instance, when a teacher doesn't show up for school because of COVID policy and testing, they'll often leave class now, and what are they doing? Are they going and vaping, are they going and smoking? We just don't know. So it's a big concern. It's an epidemic still. While we are beginning to see a decrease overall in e-cigarette use, we're seeing an increase in menthol, we're seeing an increase in Disposable and Puff Bar. So I think it's something that we really need to monitor really closely.

Jaspal Singh, MD:

That's a great summary. Jill, I'm going to take it in a different direction here at this point, just out of time constraints. The other thing, I want to thank you both for that summary, I'm going to switch gears a little bit about smoking cessation in general. We've talked for years, we've gotten back, I think, over time, in terms of counseling patients, managing things pharmacologically, and we're not going to have time to go through a whole pharmacotherapy review, but some recent data suggests that there are certain things that we can do pharmacotherapy wise to help patients quit. And so a lot of us, for example, Benacycline, a great drug for some of our patients, but it has some issues. But we also came up with shortages, all kinds of shortages for that drug for other things. And what have you noticed in terms of quitting success rates, pharmacotherapy, especially related to the pandemic and its challenges of supplies and such?

Jill Ohar, MD:

Well, I'm thinking, one of the big issues that patients who are in most need, your patients with bad COPD, or maybe even patients who've developed COVID-related pulmonary fibrosis, have a great fear of coming to doctor's appointments, or even going to the pharmacy. And so actually reaching those patients is the first challenge. And we've been incredibly successful reaching the patients for the first step, with going with virtual appointments. My personal no-show rate in the clinic office was 40%, with this kind of safety net patient population. And it's less than 5% using virtual visits. I use that opportunity every visit for people who continue to smoke, use it as an opportunity for smoking cessation counseling. It's interesting that the ATS clinical practice guidelines are advocating the use of Varenicline as first-line therapy. And interestingly, patients are still clinging to some of the early reports about side effects, psychiatric effects, suicides etcetera. So it's really difficult, I find, to get patients to embrace that as a smoking cessation product.

Hasmeena Kathuria, MD:

Yeah, so I agree. So I was part of the ATS, the guidelines on initiating pharmacotherapy. And I think there are two things that are really important when we think of tobacco dependence, it's a chronic relapsing disorder. Just like when we treat diabetes and high blood pressure, we don't ask patients if they want to be treated for diabetes. We discuss different options, whether it's diet control, exercise, medications. And so I think that's really important, that one of the most important things that we learned from the guideline is that offering treatment to people that are not ready to quit. So changing our mindset of patients who have been smoking for 30 years, saying let's pick a quit date in one year, is frightening to them. But instead saying, are you willing to engage in counseling? Are you willing to take medications that may make you make a quit attempt at some point?

Hasmeena Kathuria, MD:

And so that's where offering Varenicline and saying, you don't have to pick a quit date in one week, but let's talk about how we can make some modifications and continue taking it, and at some point, we hope that you'll be able to be ready to make that quit date. So, changing the way we talk is really important, and how we frame tobacco dependence. With the shortage, it's options. People who are afraid, really addressing mistrust, misconceptions with medications, especially our patient population that doesn't engage with healthcare, that's a lot of our counseling to address some of this. And for people who have tried it, for people who don't want it, dual therapy with NRT, nicotine replacement therapy, so the patch plus gum plus lozenge, plus the nicotine inhaler, is a good strategy, especially in shortages.

Jaspal Singh, MD:

That's really well said. Thanks for correcting my pronunciation on the medication. I think I just had not used the generic version in so long, I think I blanked on what that was. But anyways, Hasmeena, that was a phenomenal review of the challenges. I think what you're saying is, reframe, and treat this like, not something you opt out of, but something you just make a standard approach, regardless of nearly... I think what you're hitting at, is every encounter, almost, the way we attack obesity, the way we attack diabetes. I think that's a good way of addressing it. For some reason, it had this special privilege, you might say, to not be seen as a chronic condition. And I think treating it as such is probably the way to think about it. Am I right?

Hasmeena Kathuria, MD:

Yes, a hundred percent. If you think about it, only 15 to 30% of individuals are ready to set a quit date. And we know that is dynamic. Just like you were saying, Jill, when somebody has a COPD exacerbation, that's a moment where they might be ready to make a behavior change. And so understanding that it's dynamic, that people who say that they're not ready to quit, can successfully quit or stop smoking or change their behavior or engage in treatment. Those are all really meaningful outcomes, especially in our patient population that's been smoking for a very long time. So at every encounter, instead of just offering treatment for people who are ready, doing more of an opt-out approach. Let's talk about this and let's offer treatment and have patients choose that maybe now is not the right time.

Jaspal Singh, MD:

Perfect. I'm going to change it to a little bit different direction here, to talk about virtual business. Jill, the idea of, yeah, adherence is better to appointments, to no show rates. But we've also learned from some studies that actually, virtual visits have the downstream aspects of back to the at-risk populations, not having as good access to virtual care as others, the older population, not connecting with their providers as well on virtual platforms. And so when you think about personal issues of getting into behavioral psychology of tobacco cessation, how effective do you really think virtual visits are for tobacco cessation and for addressing nicotine?

Jill Ohar, MD:

I think they're great. I think that you have to anticipate challenges and I think that age is certainly an issue. I often counsel patients in advance of their visit, to check with an IT expert, which is also known as their grandchild, and have them have either a grandchild or a child or a neighbor available for help with one of those first or second visits so that you don't spend most of the visit trying to help them through the technology. I think there are platforms that are incredibly simple that you can teach people to use on the fly, the Doximity platform I use a lot, and almost everybody can use it. It's the rare person who can't.

The other thing is, is that everybody has a smartphone now. I would say less than 5% of the patients that we encounter are using the old flip phones or something like that. So I think it's possible, but there are challenges, you're absolutely right. And by inviting people to learn a little bit about the platform, which is incredibly simple, it gives them an opportunity to engage in something that their children and grandchildren really know a lot about. And they can learn from them and it helps their relationships as well. So...

Jaspal Singh, MD:

That's great. Hasmeena, what are your thoughts?

Hasmeena Kathuria, MD:

So we went to a virtual platform for our outpatient tobacco treatment, as well as our inpatient program. So during COVID, when people were in the room, we would call in and engage in smoking cessation, our counselors. And we actually had a very high show rate for our outpatient when we converted to telemedicine during the pandemic. You can reach them in the car while they're doing other things. The show rate to our outpatient tobacco treatment program is low. Many physicians are yessing their doctors. They don't want to disappoint them. They don't want to disappoint their provider. Yes. Okay, I'll go. And then they don't come. When we converted to telemedicine, we were able to reach them. So there are texting platforms that have been shown in meta-analysis to be very effective, telehealth. So I agree. I think using creativity and reaching the patient where they need, there's some that like group business, there's some that would prefer the counseling over the phone, so I think it's a great option for patients.

Jaspal Singh, MD:

Great. So, hopefully, a great option is that we can move forward and adapt from the pandemic a little bit and move forward and continue to do virtual visits for tobacco cessation. Switching gears a little bit, the Philip Morris controversy a little bit. I know Hasmeena, you're involved in some of that aspect. It's a very interesting, intriguing side story. Tell me a little bit about that one.

Hasmeena Kathuria, MD:

Well, so Vectura is one of the world's leading companies in the science of delivering inhaled medications. So they produce a lot of the inhalers that we all use, to treat our COPD patients. And Vectura was recently bought by Philip Morris International PMI, and that's the world's largest tobacco company. So you can imagine the sort of uproar from many of us in the community, that here you have PMI, who is selling cigarettes to get people addicted, and now they own the company that's making products to treat this. And so, very concerning conflict of interest. And then I think, one of the other concerns is that, while not implying intent, we worry that that same expertise that Vectura has in developing delivery to the lungs, can they use that same technology to deliver nicotine tobacco related products to the lung? And that's very concerning, especially given the youth epidemic of nicotine addiction.

Jaspal Singh, MD:

Yeah. And envisioning some type of future where they're starting to buy lung cancer drugs, or other things like that, that are interesting to think about the potential ethical issues here. Well, I just want to thank you both for taking the time to talk to us about these important aspects. And for our listeners, we have a bunch of references also on the website. But I'm going to ask our guests here today, to talk a little bit about, this series is about women in medicine, and one of the reasons for this series is actually because we've known this gender gap, we're learning more about the gender gap, now, I think it's getting a lot more attention, about the struggles that women, especially in pulmonary and critical care have, whether it be at work, at home, talk to us a little bit about any reflections on that aspect a little bit. Jill, start with you.

Jill Ohar, MD:

Well, I'm very old, so I've been on this road for a long time. When I started out, there was no such thing as maternity leave, even the idea that you would actually deem to have children. As a matter of fact, I was denied some residencies because I was pregnant at the time of the interviews. It was unusual for women to even get into medical school. So I understand. I think in many ways, while things are incredibly better now than they used to be, I think, just like the tobacco industry, they've kind of gone undercover. They've changed the way that they're addicting our children. In many ways the gender gap has changed, and it's more covert, in that women currently experience less pay. They experience fewer opportunities for leadership roles, and that continues. I think women continue to be viewed as not as strong a clinician, as a strong academician, et cetera. And these are long-held views that I think are going to take a very, very long time to change. Hasmeena, what do you think?

Jaspal Singh, MD:

Your thoughts, Hasmeena?

Hasmeena Kathuria, MD:

Yeah. I think it's, for me, it's really important to surround myself with strong women mentors. When I started in the lab, Mary Williams was my mentor and learning work-life balance, so I don't have a five-year plan, but I have a 20-year plan. I think that's really important and that's really challenging. Just like we are learning more about diversity and equity, I think continuing to keep these issues at the forefront, to have discussions, to talk about it, are all really important. And I hope we continue to make progress in that area.

Jaspal Singh, MD:

Well, thank you. I hope so too. So with that, thanks to our guests for taking the time out of their day, other busy schedules, to spend time with us. And on behalf of Consultant360, we thank you and hope you have a great day. Bye.

Hasmeena Kathuria, MD:

Bye. Thank you