Episode 15. What Everyone Should Know about Tobacco, Smoking and Vaping


Episode Summary:

Reasons, support, empathy, data, apps, and resources for not smoking or quitting smoking are abundant (thank you public health!) and covered in this episode. While tobacco use has declined, the use of high-tech nicotine delivery devices—e-cigarettes and vaping—is replacing it, especially among youth. There are a lot of unknowns about this new trend.

Episode Guests:

Sarah Ross Viles, MPH: Director of the Tobacco Studies Program University of Washington, former Chronic Disease Program manager Public Health, King County Washington.

Tim McAfee, M.D. Affiliate Assistant Professor, Health Sciences University of Washington, Former Director, Office on Smoking and Health, Center for Disease Control and Prevention. Consultant with the CDC Anti-Smoking Media Campaign

During This Episode We Discuss:

  • Tobacco and Tobacco products, If you smoke, if you’re considering smoking or if you know someone who smokes, you need to listen to this episode.
  • The manipulation of the population by the tobacco industry. How to make a product very addictive and how to do the communications and public relations and lobbying to make the environment receptive to tobacco.
  • Lung Cancer is essentially a disease of smoking.
  • COPD.
  • Smoking makes treatment for cancers less effective.
  • Smoking and smoking-related diseases on other conditions….smoking will exacerbate all the consequences you could experience (Diabetes, Pre Diabetes, HIV, Substance Abuse, or a mental health issue).
  • Cutting down on smoking does not mitigate risks (Cancer, Cardiovascular disease).
  • Oropharyngeal cancer association.
  • Vaping the terrible addiction.
  • Stopping smoking is the one of the single most beneficial things you can do for yourself. You will add 10 years to your life expectancy, if you quit in 30’s or 40’s
  • Smoking Cessation, real strategies, even if attempts to quit have failed, further strategies.
  • Money saved by smoking cessation.
  • Underuse of support, use support to quit more regularly and vigorously.
  • Don’t think ‘I failed’ if you tried to stop, think instead of a partial success. Keep trying.

Quotes (Tweetables):

“The suffering caused by smoking, that’s one of the big myths about smoking, because people, especially when they’re younger think that they will just die younger, but what we really found that helps motivate people is not that you just die younger, you die harder, that there’s much much more suffering.”

“I would mention regarding cancers, this is less known to people, it’s important in men’s health, Bladder Cancer and Kidney Cancer are both markedly increased and a large chunk of those cancers are caused by smoking”

“Quitting smoking is like riding a bicycle, you have to get on it and fall off it a few times before you figure out how to do it. Most people if they keep at it will figure it out. If you don’t keep trying or try, you’re chances are essentially zero.”

Tim McAfee, M.D.

“…How the tobacco industry and the companies that make up the tobacco industry could profit off of what is a deadly, lethal product that is sold legally to everyone in our country and around the world. I found that tradeoff between corporate gains and the devastating health effects to be really interesting, and that sparked my passion for public health”

 Sarah Ross Viles MPH

Recommended Resources:

Episode Transcript: 

Narrator (00:07):

A baseball game, a day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures. Whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health is presented by the Washington State Urology Society to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body. After all, it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body. If you know you should, but haven’t yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast as we explore men’s health with renowned experts and embark on a journey towards better health. 

Dr. Richard Pelman (01:20):

While you absolutely need to know about tobacco, smoking, and tobacco products, if you don’t listen to another episode, listen to this episode of the Original Guide to Men’s Health. On this episode of the Original Guide to Men’s Health, we’ll be reviewing smoking, tobacco use, and vaping with two experts in the field. It’s my pleasure to be here with Tim McAfee. Tim is an affiliate assistant professor of health sciences at the University of Washington, and the former director of the Office on Smoking and Health for the Centers for Disease Control and Prevention. He now serves as a consultant with the CDC in the anti-smoking media campaign. We’re also here with Sarah Ross-Vials, MPH. Sarah is the director of the Tobacco Studies Program at the University of Washington and former Chronic Disease Program Manager at Public Health – Seattle and King County. Welcome. I think what I would like to have you both do is just give a little bit of background as far as your expertise in overall smoking. We’ll be covering issues of the ills of smoking, some of the things that some people listening are already familiar with, and perhaps many things that they’re not. We’ll be covering smoking and tobacco products, vaping, and prevention. So Tim, why don’t you start it a little bit, just give a little background about what you’ve done as far as with the CDC and some of the campaigns.

Dr. Tim McAfee (02:46):

Sure. Well, I just mentioned that before I dive into what I did most recently with the CDC is that I had also worked for many years as a primary care doctor in the Seattle area and that’s where I really first developed a passion for trying to help my patients quit smoking and was very excited as I gradually learned that there was far more that I could do to help people than I’d been taught in medical school. So that’s how I first got interested, and I did a whole lot of work in this area around that, and then got recruited to go and work for five years at the CDC directing their office on smoking and health, which works with all the states around the country. And then I also had the honor of working on the first major national federal media campaign tips from former smokers, which probably anybody who smokes is aware of these ads that have featured people who had illnesses related to smoking and who quit successfully from doing that. But talking about the suffering caused by smoking, because that’s one of the big myths about smoking is people, especially when they’re younger, they think they’ll just “die younger.” But what we really found was, and what helps motivate people, is not just that you die younger, it’s that you die harder and that there’s much, much more suffering for the many, many millions of people that have chronic conditions related to smoking. 

Dr. Richard Pelman

And Sarah?

Sarah Ross-Vials (04:09):

I got into tobacco control and prevention because I was very interested when I was a graduate student in public health about how the tobacco industry and the companies that make up the tobacco industry could profit off of what is a deadly product that is sold legally to everyone in our country and around the world. And I found that tradeoff between corporate gains and the devastating health effects to be really interesting and it really sparked my passion for public health. I didn’t start with a primary individual aspect of public health, but much more looking at populations, and when I worked with my students and when I did programs at the health department, we very much looked at what are the environmental causes of smoking. It’s really likely that most people conceptualize, “oh, if someone’s addicted to smoking, if they’re addicted to nicotine, that’s their fault, it’s a choice they made, they wanted to look cool, so they did this.”

Sarah Ross-Vials (04:57):

The science around using tobacco products is really that there are so many factors, you know, about the individual, but also about the people who are around them, the environments they’re in, and even the policy environment that really drives whether or not someone is going to smoke or whether they have opportunities to quit. And at King County, I had the opportunity to work on the implementation of Washington’s smoke-free ban, one of the strongest bans in the nation at the time that started in 2006. And we also worked on when e-cigarettes and vaping products came to market. Our King County board of health adopted some of the first policies to make sure that those couldn’t be sampled and sold in places where kids were already frequenting. So there are these very important environmental aspects, but we might think of smoking as an individual habit or addiction. There’s some really important environmental steps that make our populations healthier from smoking.

Dr. Richard Pelman (05:55):

So let’s review some of the ills from smoking. I can’t think of a body system that is not affected by smoking. 

Dr. Tim McAfee (06:02):

Well I’ll kick it off, and as you say, it is challenging because there really is not an organ system in the body that isn’t affected by smoking. And the ones that people are the most familiar about are really, it’s the portal of entry for smoke, from cigarettes. It’s the lungs. And it’s in the lungs that you get the two biggest killers in chronic disease. You get lung cancer, which literally people are about 20 times more likely to get if they smoke than if they don’t. Lung cancer is essentially a disease of smoking. Only a tiny fraction is caused by anything else, including secondhand smoke. And then the other one is chronic obstructive pulmonary disease which is basically that the smoke breaks down the little tiny sacs inside your lungs and makes it so your lungs just can’t efficiently get oxygen to the bloodstream.

Dr. Tim McAfee (06:51):

Both of them are pretty grim ways to die. And everyone that works deeply with patients around this has emphasized to me, around particularly both of these conditions, the preventive treatment is to not smoke or to quit, and even if you have particularly, say COPD, the only really effective treatment is to quit. I would just mention also, just hitting cancers less known to people, and this is very important in men, bladder cancer and kidney cancer are both markedly increased and a large chunk of those cancers are caused by smoking. And again, quitting decreases your chances of getting it. And another really important thing that we found out just in the last decade is that it isn’t just that smoking causes cancer, as if that were enough, it’s also that if you get cancer, smoking gums up your prospects. It makes treatment less effective and you have a harder time tolerating treatment, and your chances of recovering fully are decreased if you smoke. This is even true for some cancers that are less associated with smoking, like breast cancer and prostate cancer. It’s very clear that smoking makes it worse if you get these cancers, even if it didn’t cause it. And then again, there’s many cancers that are caused that I could go on and on, but I’ll stop there. Sarah, what else do you think is important for people to know that they may not know?

Sarah Ross-Vials (08:17):

I think something that might not come to mind for folks, especially people who have grown up as we have in the world of anti-tobacco advertisements and really great health campaigns, is actually thinking about the overlap or cross effect of smoking and smoking-related diseases on other conditions. So what we would call comorbidities and a health world. And some of my students have been really stunned by the effect that, say you are diabetic or pre-diabetic, to the effect that smoking will have to exacerbate all the consequences that you could experience or many of the consequences you could experience from diabetes. Similarly with HIV, one population that has a very high proportion of smoking is folks who are experiencing substance abuse or have a mental health issue. And there’s actually evidence that without quitting smoking, it’s actually harder to quit other addictions at the same time that there might be some co-benefit in quitting both. But we have systems that don’t necessarily think of those things as beneficial to each other. It might even see quitting is something that’s too hard to do when you’re addressing other drug use. And so that’s, I think, some of the newer conversations that are important to have when we think about what is the health impact of tobacco. It’s not always a direct effect as Tim was talking about with cancer consequences.

Dr. Richard Pelman (09:31):

Are cardiac disease and peripheral vascular disease associated with smoking?

Dr. Tim McAfee (09:36):

Yes, extremely important. Although the effect is not as large as it is around long, it’s not a 20-fold increase. It’s probably a three to four-fold increase in your risk of heart disease. And if you have a heart attack, again, the most beneficial thing you can do for yourself in terms of not having a recurrent heart attack in the next year is to quit smoking and cut your risk in half. And this is one, heart disease is interesting because a lot of the other, particularly the cancers, you have to smoke, you know, 10 years, 20 years before you really see dramatic increases in your risk. But heart disease, exposure to smoke has almost literally immediate effects on your risk for particularly having a heart attack or stroke. This is true for secondhand smoke. There’s some really clever studies that were done where they looked in towns where they passed a non-smoking ordinance and they would then see dramatic, measurable decreases in emergency room admissions or visits and then at hospital admissions for heart attacks that then went back if they changed the ordinance back to allow people to smoke. And so you see some of the most dramatic benefits immediately within days to weeks to months when people quit smoking around their heart risk.

Dr. Richard Pelman (10:49):

And oropharyngeal cancers?

Sarah Ross-Vials (10:53):

I want to add on to what Tim said, because I think there’s an important part, and we’ll talk about cessation I’m sure in a little bit, but one of the implications of what you’re saying, Tim, that I think is something that people don’t recognize is that because it is such an immediate exposure to tobacco smoke that’s linked to cardiovascular effects, cutting down on smoking doesn’t have the same effect as quitting entirely. There’s actually a pretty low dose response, which is that it doesn’t take much tobacco smoke to cause the cardiovascular effects. And so a lot of folks might think of a process of quitting as, “oh, if I just go to a very low exposure,” but in fact, that’s not as protective as we think it is, which really ties up to what you were saying, Tim, about how we see this immediate exposure and immediate health effect.

Dr. Tim McAfee (11:35):

Yeah, that’s an incredibly important point that I would underline. And this was something that was one of the findings in a surgeon general’s report that was released about five or six years ago that really took to our surprise. Something that we had assumed would be beneficial in terms of harm reduction, which would be like if you smoked a pack and a half, if you cut down to one pack or cut down to three quarters of a pack, that you would think that that would cut your risk in half. But there’s just very definitive evidence that that’s in fact not the case. You don’t see dramatic effects on health in quitting until you get down to very very minimal, or really ideally none, because of the cardiovascular effects. And this is very important as well. If we talk more about e-cigarettes and vaping, that’s one of the issues and concerns around how most smokers are currently using it in the United States. That they’re more using them as a tool to cut down than they are to quit completely. And again, that’s a very dangerous strategy that, and again, that one was pushed by the tobacco industry and for which we now know is really bankrupt in terms of improving your health.

Dr. Richard Pelman (12:49):

The men who come see us with erectile dysfunction and the nicotine vasoconstrictive, or narrowing of a blood vessel effect, on the ability to get blood flow into the erection bodies and we tell men, “look, don’t smoke and it’ll improve your ability to have a satisfactory erection.” And I’ll also say if the side of the cigarette package said, “the surgeon general warrants that smoking is related to erectile dysfunction,” guys would be throwing packs out by the dozens. But they don’t say that I don’t think. I had asked earlier about the association with nasal or oropharyngeal cancers, and I do that in part also because another men’s health issue is HPV. And is it a one plus one equals 20 association if you’re inoculated with a certain strain of HPV and you smoke, you’re going to make things worse, or is there any research or data on that?

Dr. Tim McAfee (13:32):

Yeah, it’s certainly at least additive. But I’m not clear if it actually multiplies your risk, but clearly it’s an incredibly bad idea to smoke if you have HPV, which gives you a risk factor for oropharyngeal cancer. I would add this is certainly, I got to know a lot of the people that worked on the ads that we did around oropharyngeal cancer, and I really had a lot of respect for how people ended up figuring out how to live with not have your voice box so that you have to use a mechanical device to be able to talk. There’s one incredible ad that Terry Hall, who’s the most famous tips ad participant, who had laryngeal cancer who talked about how her granddaughter had never been able to hear anything but her mechanical voice, you know, she’d never heard the richness of what had been a beautiful voice that she’d had.

Dr. Tim McAfee (14:24):

And there are little things like that, which aren’t really little when they actually happen to you, that again, I think if smokers appreciated what was going on, because there’s really almost nothing else, perhaps nothing else that you can do, that will benefit your health as much as quitting smoking. So that’s pretty amazing because most things are a lot more complicated: changing your diet, even exercise. There’s more controversy. But here’s one thing that you can do that’s just kind of binary. You just stopped doing this one behavior. And the other thing, it’s probably worth mentioning, or may not motivate people, you will add 10 years to your life expectancy by quitting, on average. If you quit in your thirties or forties, and even if you quit in your sixties, you’re still going to add four or five years to your life expectancy.

Dr. Tim McAfee (15:18):

This is an enormous, enormous impact and it’s something that we understand the details of around a risk far, far better than we do around most things. You know, we’re not having the kind of arguments that you have around diet change, where one year something’s bad and then the next year we’re not so sure, and vice-versa. We have now known for decades just how horrible smoking is, which is not to say that it’s easy to quit, and people should not feel guilty or ashamed or afraid to seek assistance if they are continuing to smoke and having difficulty quitting, because it’s extremely challenging to do.

Dr. Richard Pelman (15:57):

So let’s look at, so many people smoke, why if it’s bad? When people take their first puffs, it doesn’t seem natural. They cough, they get used to it. Is it fair to say smoking is truly an addiction?

Sarah Ross-Vials (16:12):

I think it’s certainly fair to say smoking is an addiction. Nicotine is highly addictive. It’s a really difficult addiction to break as well. You’ll hear it, you know, I’m sure, you can attend a lecture here at University of Washington where you hear it compared to heroin in terms of addiction. But beyond that, it is these environmental factors. You, Rich, mentioned earlier, the warning labels on cigarette packs. What you might not know is that those have been very much influenced by the tobacco industry themselves. And you talked about how powerful it would be to have a certain message. Well, the FDA actually came up with more powerful visual messages about five years ago, and the tobacco industry took them to court to get those images thrown out because they had too much of an emotional appeal to folks. And they thought that was a violation of their first amendment rights to be compelled to give an emotional warning on their label.

Sarah Ross-Vials (17:02):

So the tobacco industry has been extremely successful, not only at creating environments where smoking seems like an okay thing to do, even though we know the negative health risks, they’ve also been extremely skilled at going after the folks. And you talked about taking your first puff and when you cough, and the image that I have in my head, when you say that is a 12 year old, a 13 year old, a 14 year old. These folks, as Tim talked to who aren’t thinking of the consequences who are thinking, I’ll be able to quit when I want to, and also just don’t have the kind of thought and development to be able to consider what those health consequences mean until they end up in a point where they’re addicted. And we have, at this point, the knowledge of being able to go through documents that were kept internal to the tobacco companies that were released during a major national lawsuit almost 20 years ago, called the Master Settlement, where a lot of documents were made available, and great researchers have gone through those documents and found the inside thinking of tobacco industry executives saying things like our consumers are dying, we need replacement smokers.

Sarah Ross-Vials (18:02):

And we mean children when they say that. And quotes around, “but we have to use flavors and products,” you know who likes the flavors of lollipops and these other things where they’re very intentionally appealing to a group of people that aren’t an adult consumer who have the knowledge that we have. And they are all at the same time adjusting the product itself to be more addictive. The amount of nicotine in cigarettes has gone up drastically over time. And until 2009, we actually had no way to regulate how much nicotine was in the cigarettes, or really regulate the product in any meaningful way until the FDA got regulatory control of the products in 2009. So we’re playing a lot of catch-up with an industry that has had decades, almost a century, to refine how to make a product very addictive, and also to do the communications and public relations and even lobbying to make the environment really receptive to that product.

Dr. Tim McAfee (18:59):

I would totally agree with everything that Sarah said. Maybe it would be helpful for me just to talk a little bit about what we know about how people can actually quit in case, because I don’t want us to feel like we’ve just sort of, you know, had people melt into a puddle of feeling like there’s nothing that they can do around this. So the good news is that we’ve also discovered a lot, particularly in the last 20 years, about how to help people quit, even though it is highly addictive and even though essentially the tobacco industry has managed to do a whole bunch of things that make it harder to quit by having advertising and by having the product so easily accessible that it make it harder than something like heroin or cocaine. So basically the formula for quitting that has been shown to work is number one, getting in touch with your motivation for why you want to quit.

Dr. Tim McAfee (19:59):

And this is also true with exercise and diet. Anytime you want to make a significant behavior change, it’s getting in touch with your deeper reasons for why you want to do this. And for most people that has to do with health, but it also has to do with effects on their loved ones. If somebody has kids then maybe they want to set an example. It can also be just financially that it’s becoming incredibly expensive to continue smoking. But whatever it is for you, exploring that and understanding it. And then the two big things that we now understand that have been added in the last 20 years is medications, and some forms of coaching or counseling. And we know a whole lot about what works for those. We now have seven different medications that are available to help people quit. Five of them are just variations on nicotine, which paradoxically is helpful to quitting when used in one of the FDA medications, the gum, the patch, the lozenge, particularly.

Dr. Tim McAfee (20:56):

And then there are also two medications, Varenicline and Bupropion, that can be taken as pills, that work that are effective. The other thing that we’ve just learned much more recently, perhaps in the last five years, is that it is not only safe to take two medications together, but it also increases your likelihood of success. And the most common combinations of this is to use a nicotine patch, which provides a base of nicotine to sort of keep you from withdrawing, from stopping cigarettes, but also then using on top of that, something like a gum or a lozenge for breakthrough urges. And this has definitely been shown to work better. There’s lots of, kind of, mythologies around nicotine that make people more reluctant to use them, most of which have been debunked. People worry that nicotine is the bad thing in cigarettes, which it’s the addictive part of cigarettes, but it’s less of a concern around things like causing cancer and COPD and all those kinds of things.

Dr. Tim McAfee (21:55):

And these medications are mostly designed to be used for a relatively short period of time, like weeks to a few months. And in those circumstances, there’s really no medical concern about using them compared to cigarettes, not at all. And Varenicline has also been shown to be very, very powerful, probably the same effectiveness as using two forms of nicotine replacement. It has the added benefit of probably decreasing people’s cravings. So people can start it a week before they quit. There are lots of details about this. And the other thing I would urge people to do is to talk to your physician, talk to your pharmacist, to get more inspiration but also direction on how to use these medications effectively. The other thing that we found is we’ve been able to make it more convenient for people to get help because one of the big problems was people just didn’t want to have to attend a class to quit smoking for a bunch of reasons. Now, attending a class is a great thing to do. It works. But most people don’t want to do it.

Dr. Tim McAfee (22:54):

So the things that we can do that are easier to do is bringing it up when you’re going in to see the doctor anyway, for some other reason, or making a special appointment. But we now have these things called quitlines, which I think most smokers have at least heard of, and I spent a decade working to try to make quitlines be stronger and better, including to be able to actually get free medications by calling 1-800 QUIT-NOW, which is the telephone number that is coordinated by the National Cancer Institute and the CDC and the state health departments. And those are staffed by literally, probably thousands of quick coaches at this point that have been trained to help any smoker at any stage. It doesn’t matter if you’re not sure you’re ready to quit and want to talk about that, or if you just quit, or you quit a month ago and want help, or you’re not even a smoker yourself, but you’ve got somebody that you want to help quit. The coaches are all trained to be able to handle all these different situations and at no cost to the caller.

Dr. Richard Pelman (23:54):

And that’s found at what number?

Dr. Tim McAfee (23:57):

1-800-QUIT-NOW, and that connects you with whatever service your state health department is supporting.

Dr. Richard Pelman (24:05):

Is that advertised at every tobacco stand and place that sells cigarettes?

Dr. Tim McAfee (24:10):

[Inaudible] it is not. In other countries they are doing that. They’re even putting it on the cigarette pack itself. And that was actually one of the things the FDA wanted to do as Sarah alluded to back over five years ago, and that got squashed by the tobacco companies. So it is added on to the advertisements that are being done in the quits campaign, and the states do them as well. But it is not as advertised as much as it ideally would be.

Dr. Richard Pelman (24:38):

So we’re dealing with a tremendous addiction. I’ve had patients tell me that they quit, but every time they smell cigarette smoke, they still want one. There’s something that happens in the receptors in your brain. Obviously people keep smoking. So it’s wonderful to have solutions. Some people don’t have a primary care doctor or a physician. So somebody in the population who smokes and wants to quit now has a resource. Any other resources online or other places where people can find help?

Sarah Ross-Vials (25:04):

Smoke-free apps or quitting apps are developing pretty briskly right now. So I believe smokefree.gov has an app. If folks are more inclined to do their health behavior change on their phone, which I think a lot of people are these days, the smokefree.gov would be a resource for that.

Dr. Tim McAfee (25:25):

Yes. And it’s got a bunch of different programs. It’s got a program for youth, it’s got one for women, it has one for veterans and active duty military, and you can download an app specifically to it. You can get texting messages. You can sign up for a texting program that will support you while you quit, for which there is evidence. Smokefree.gov. There’s another one, becomeanex.org, which is done by the Truth Campaign. And there’s growing evidence that websites and apps are effective. The thing is, it’s like, with everything else around quitting smoking, the more you use it. And then it applies to coaching, it applies to websites, and it would apply actually to the medications themselves. The biggest problem that people have, where the medications are not effective, is they underuse them. This is far more of a problem than overusing them.

Dr. Tim McAfee (26:16):

People will just use them for one or two weeks and maybe not use as much. So all those things, it’s really making sure that you, if anything, overdo it with getting that kind of assistance. I would just add the one other thing though, I don’t want to scare anybody off by thinking if you’re thinking about quitting smoking, that you have to do a bunch of things. And this is something that we decided that we were going to be sure to avoid. When we ran this big campaign, the emphasis is quit! Try to make a quit attempt. We would encourage you to call 1-800-QUIT-NOW to think about using a medication to talk to your doctor. But the most important thing is to attempt to quit. Most people it’s like riding a bicycle. You have to get on it and fall off a few times before you finally figure out how to do it. But most people, if they keep at it, will figure out how to do it. But if you don’t keep trying or try, then essentially your chances are zero, particularly because nicotine is so addictive.

Dr. Richard Pelman (27:15):

And that is a great point. I was going to ask if somebody says, well, I tried, and I failed. They should keep trying.

Dr. Tim McAfee (27:20):

Totally, totally. I mean, what we like to do is encourage people to reframe it. It isn’t that you fail, it’s that you had a partial success. And just like if you fall off a bike or anything else you’re learning to do, a skill that you’re learning to do, it takes time. And you just think, why did I fail? What were the circumstances that I quote unquote failed? Was it that I went out for a drink after work? People were going out to smoke and I felt embarrassed if I didn’t go out? Or was it something completely different? And then try to figure out what that was. And then the next time you quit, you can either avoid that or you can figure out some other way to deal with that so it doesn’t cause you to relapse.

Dr. Richard Pelman (27:59):

And I hear from patients, well, I’d like to, but my spouse still smokes, and so it’s very difficult for me to stop. What do you do when you have couples that smoke?

Dr. Tim McAfee (28:10):

Well, that is a challenge because anything to change a really difficult behavior like smoking, if your environment is kind of reinforcing smoking, obviously having somebody in your house that smokes, is a challenge. So, I mean, one approach is to explore the possibility if the other person would like to do a joint quit together. And I think that’s a great thing to do as long as you just have to be careful that you don’t make your success contingent on the other person’s success. You both have to kind of agree that you’re going to try to do this together, and both also need to commit to not sabotaging the other person. And if the other person is not ready to quit, they can still agree on smoking rules around the house. Like people don’t, you don’t smoke in the house. Even if both parties smoke, you’re not going to smoke in the house because that makes it so much harder to quit.

Dr. Richard Pelman (29:01):

And if we looked at the economics of smoking cessation, I know that there are employers who will give you a break on what you pay for health insurance if you voluntarily enter into smoking cessation. But just the economics of what you’re spending on cigarettes? Have you looked into that reward that comes back to people?

Sarah Ross-Vials (29:23):

It’s thousands of dollars. And often in the classes that Tim was talking about, or if you’re talking with a quick coach, they will review that with you. If the financial piece is one of your motivations, and it might not be for somebody, but for a lot of folks it is, as you’re paying in Washington at least 6, 7, 8, 9, $10 a pack, and a pack a day, that gets pretty expensive. And I’ve certainly worked with folks who’ve said, well, in three months I can buy the stereo I want to buy, and set that kind of goal. And that works for some folks. And some folks, they’re just dealing with the day-to-day of trying not to pick up the next cigarette. And that’s a longer-term thing that might not be in their mind.

Dr. Richard Pelman (30:02):

So with their time being limited, I would love to go on just with smoking. But there are other tobacco products that I, and vaping, and I really want to address those. Let’s start with just tobacco products. I’ve seen, unfortunately, high school athletes with tobacco stuck in their cheeks. It’s still harmful. Go ahead and just give a little background and the issues there.

Sarah Ross-Vials (30:26):

Yeah, smokeless tobacco. It doesn’t have all, or many, of the same health risks as combustible tobacco because there isn’t that exposure to the lungs, but you were talking about oral cancers and that’s certainly linked to smokeless tobacco use. Hookah use is another thing that’s rising in popularity with youth and young adults that I see around campus here at the University of Washington. It’s funny to look at where hookah lounges open up. It’s usually close to where you’ll find a bunch of young people. What other alternative products besides vaping are on your mind these days, Tim?

Dr. Tim McAfee (30:58):

The only one that’s kind of going up at a dramatic angle is e-cigarettes and vaping. So we probably should focus on that, but I think hookah is potentially dangerous. The bottom line is that tobacco, we also have to realize that the tobacco industry is a very robust and dynamic force that is not just going to pack up and go home because use of one of their products is going down. I mean, we’re seeing some remarkable successes with youth around cigarettes. For instance, where we’ve gotten now, California, believe it or not, in their most recent survey that just came out, cigarette use in middle school and high school is at 2%. 2% down from 4.3% two years ago. So it’s almost like cigarette smoking has collapsed. The market has collapsed in adolescence. There are other countries like China, like Turkey, parts of Africa, where nobody smokes.

Dr. Tim McAfee (31:53):

I mean, literally nobody smokes. Smoking is like 2% until they hit 18 or 19 or 20 and then suddenly it goes up and in China, you know, if you’re a male, it’s 50%. So we’re not out of the woods, even though that’s very, very encouraging, and things like hookah are one of the things that can come in. And then of course the other big one that we’re looking at the most closely is vaping. Basically what these products are, they’re called e-cigarettes or vaping, that’s what they really are, is they create a thing called an aerosol, which is a bunch of little tiny, tiny particles suspended in air, but it’s not really, vape is actually a gas. They’re not gas, they’re an aerosol, which are tiny, tiny ultra-fine particles. And it’s an ingenious device that was created by a guy in China about 15 years ago, because he wanted to try to help people quit smoking.

Dr. Tim McAfee (32:40):

So that was his original motivation. And what has happened has been this very confusing situation where you have something that could potentially be helpful, because it’s predominantly nicotine and we know that nicotine replacement therapy helps quit, but it’s now being particularly marketed. It’s essentially been mostly taken over by very large companies. There’s one company that makes the product, Juul, that’s responsible for 70% of the e-cigarette market and Altria, the makers of Marlboro, just purchased about a third of it, six months ago. And the large tobacco companies are sort of taking over the marketplace around us. So, and they have, they’re going to hedge their bets. They don’t mind making money selling these things. But they’re not going to cry too hard if they also help people keep smoking. So we have to look very carefully at this and what’s happening in the US is that mostly, like 80% of smokers that are adults that are vaping or using e-cigarettes, are also smoking cigarettes.

Dr. Tim McAfee (33:38):

And as I mentioned earlier, that’s not a good equation. If you’re doing both, that’s clearly not. That’s not a good outcome. It’s more complicated if people are only vaping. Like if an adult switches from using cigarettes to only using, if they use it to vape for a couple of months, and then they quit vaping, that’s obviously a success story. But that’s a relatively small amount of what’s happening there. There is a significant number of people switching to vaping, but more of them are keeping smoking. So if you only vape that, honestly, the problem is that this is one of those things in health, in medicine and in public health, where the thing that’s scary is that we don’t know. There are credible people who are absolutely convinced that if you switch out cigarettes to e-cigarettes or vaping devices, that you cut your risk by 95%.

Dr. Tim McAfee (34:27):

So you’ve only got 5% of the main risk. There are other people that are, I think probably a little more credible, who think it’s at least 70% of the risk of smoking. So you’ve really not done much of anything around us. Even 5% is still pretty significant because smoking is so, so awful. 5% is still probably worse than 95% of the other things we worry about. But it would be something dramatic if we cut down to 5%. The concerns that they’re unclear are because it’s not a gas, it’s not really a vape. It’s aerosol. It’s very fine particles. And there’s some effects, particularly around heart disease, but also some lung disease, that may be influenced just by the fact that you’re inhaling all these millions and millions of very fine particles. And it’s true that they’re not the nasty chemicals that are in cigarettes, but there’s still millions and millions of tiny little particles.

Dr. Tim McAfee (35:15):

And the short story is we just don’t know. And I’d say a lot, almost everybody thinks it’s less risk, but nobody thinks it’s no risk. And some people are still quite concerned that we’re overestimating the benefit. Clearly the safest thing to do is to just quit cigarettes, period. There’s been one good study that looked at about 800 people that was just done in the UK where they basically treated them like a medication. You know, they randomized people to either get nicotine patches or gum or whatever, or get the vaping device. This was not an e-cigarette though. This was a tank system that was more sophisticated than most people are using. And that looked very promising. It looked, I mean, it looked more than promising. It looked like people that used it with, but they got a lot of counseling. It was sort of like designed to create the maximum effect. And in that one, something like 18% of people at a year were not smoking cigarettes. Now 80% of them were still using the vape device. Whereas the people that had used the NRT product, only 9% of them were using it. So again, it gets back to, how satisfied are you if you’ve gotten people off cigarettes, but they’re still using nicotine that they’re inhaling through their lungs. That’s unclear. 

Sarah Ross-Vials (36:28):

And the danger beyond, Tim, what you mentioned of, we don’t know the long-term effects, the health effects of these products. You know, if it’s not clear to folks listening, the danger of putting tiny particles in your body is they can get to places they’re not supposed to go, right? But they’re also, as to mention, these products are being made or bankrolled by the same companies that have sold cigarettes for decades and decades and decades. And so while we have a success story with youth smoking rates going down, as we talked about in California, not as low, but similar in Washington state, the youth use of overall tobacco products, so if you include the vaping products, is going up like we have not seen it ever go up since we started doing tobacco control, because it’s mainly been going slowly down, and in Washington, that looks like a 50% jump between two years of data.

Sarah Ross-Vials (37:15):

So we surveyed 10th graders in 2016 and 2018 and again, half as many are using these products. And what has really struck me about looking at our most recent youth data is that 10th graders who are using tobacco products in Washington, almost half of them wish they could quote, “stop right now.” That’s their selection. So we have very young people who are addicted to nicotine in a very unintentional way and these products, if you see them, they’re meant to be social products. The Juul has a party mode that if you hit the button, it lights up in a multicolor way and then your friends can hit the button. There’s lots of youth culture around sharing your Juul or using it, you know, where can you use it at school because it’s very undercover? So, youth are really getting into a practice and a culture that’s just alluring and that attracts teens in a way to social groupings, to cool technology.

Sarah Ross-Vials (38:01):

We’ve had youth tell us in focus groups, you know, one of the reasons why the vaping products appeal to them is they kind of say, why would I use a flip phone? Why would I ever smoke? I got an iPhone right here, meaning the vaping products, that this is the next generation, and there’s no going back. And so it fits that technological appeal, but they’re not at all thinking about the nicotine content and what that sets them up for.

Dr. Richard Pelman (38:29):

Yeah, I can’t imagine that nicotine is good in a developing body. I mean, it’s not good for adults, but let alone a developing body. And for somebody who wants to reach potential in mental potential and physical potential, it’s a sad story.

Dr. Tim McAfee (38:42):

There’s a lot more that’s been coming out in the last five years about nicotine’s effect on the brain, particularly the developing brain. And you’re absolutely right. So this is I think really important for men or parents, because this is truly an epidemic associated with one product, Juuls predominantly, that have just taken off like wildfire and are far more dangerous than kids have any idea of. In this recent survey they did in California, they found 25% of the people who were using Juuls didn’t know if they had nicotine or not. 10% thought it didn’t have nicotine. And this is a product that has more nicotine in it than cigarettes do. So lots and lots, you know, thousands and thousands and thousands of kids, hundreds of thousands of kids, are getting addicted to nicotine from this one product and we really don’t, I mean, I don’t think there’s any rational way you can come up with an argument that this is good for anybody. We didn’t need to have that happen to get kids to not smoke cigarettes. We had plenty of other tools in our toolbox for how to keep kids from using cigarettes. It’s great that kids aren’t using cigarettes, but having 15%, 20% using a vaping product at 14, 15 years old is something that parents need to, and teachers, really need to be paying attention to.

Dr. Richard Pelman (40:01):

Yeah, it really sounds like a public health disaster. You know, you have young kids who have peer pressure. As Sarah said, it’s something really cool that delivers the product, and it’s addicting. And so parents should be absolutely aware that vaping is not harmless. Is that correct? 

Dr. Tim McAfee (40:16):

That is correct. 

Dr. Richard Pelman (40:17):

And kids should be aware that they’re not going to develop their full potential by vaping, correct?

Dr. Tim McAfee (40:23):

That is correct. And they will be addicted to it. So in other words, something is happening to you when you’re 14 or 15 years old, that you will be stuck with. You know, your brain is going to have been altered in a manner that not only has negative effects on things like your ability to do schoolwork, we think it may increase things like attention deficit or other problems with behavior.

Dr. Tim McAfee (40:49):

But also regardless, even if it did none of those things, it means you’re going to be stuck for the rest of your life having to shell out money to purchase a product that, you know, you may have thought was cool when you were 15, but when you’re 25 or 30, and 90% of adolescents, whether they smoke cigarettes or Juuls, they all think they won’t be when they’re in their twenties. But 80 to 90% of them will be.

Dr. Richard Pelman (41:09):

So as we run to the end of our segment, any last thoughts? I know we would all say, just don’t start smoking or vaping, but any last words to the audience?

Sarah Ross-Vials (41:21):

I think going back to the point of quitting as probably the best thing you can do for your health, if you’re listening and you can do it, you can use resources to do it that we’ve talked about. Or you can just give it a try and see what you learn. And if you’re someone who is not currently smoking, it’s a conversation you can have with people around you. And especially Tim, I appreciate that you brought up parents as well, because just, there’s a lot of protection and just being able to talk with your kids about substances that they might use, and that itself is what I would consider a public health intervention.

Dr. Tim McAfee (41:52):

Yeah, ditto, I think we’ve covered the waterfront. And I would just emphasize to people that if you smoke, quit as soon as you can. Know that there’s help out there. We encourage you to use it. But even if you don’t want to use help, figure out a way to quit. And if you don’t smoke, which most people don’t know, be supportive of your fellow human beings that do because it is a very challenging thing to stop and most people wish that they didn’t. And so being empathetic is an important part of what we can do to help smokers. And lastly, there’s still going to be more things that are gonna happen in the next few years at the national level, hopefully, and at the state and local level to try to essentially make it harder for kids to get hooked and easier for adults who want to quit. So we need to keep our antennas up for all these kinds of things that Sarah was talking about on policies to make it essentially more friendly for people to not have to keep using tobacco products.

Dr. Richard Pelman (42:51):

Well Dr. Time McAfee, Sarah Ross-Viles, I truly appreciate your being here. And I just hope people are listening. Take it to heart, play this back and listen, and listen again, and play it for your friends. It’s probably one of the most important things we can do to preserve better health.

Narrator (43:11):

This completes another podcast chapter of the Washington State Urology Society’s, Original Guide to Men’s Health. This is Dr. Richard Pelman reminding you to take care of yourself. Washington State Urology Society wishes to thank all contributors who volunteered their time and knowledge. The information presented is the opinion of the speakers. The society also wishes to thank Shawn Fox for his invaluable technical assistance. The music theme, San Juan Bells, was written and performed by Dr. Dave Whiting. The podcasts are the property of the Washington State Urology Society. Reproduction and use without the express consent of the society is strictly prohibited. For more information about men’s health visit wsus.org or visit your physician or care provider.

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