Ask Us Anything About… Smoking and Vaping

Smoking remains the leading cause of preventable death in the U.S., killing nearly half a-million Americans each year. We'll talk about the dangers of tobacco and strategies for quitting – along with the rising popularity of vaping – with Jonathan Foulds, professor of public health sciences and psychiatry at Penn State College of Medicine.

January 22, 2018 Penn State Health News
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Transcript

Description – The video begins inside the Penn State Cancer Institute. Two people are standing next to each other looking at the camera. From left to right is, Scott Gilbert and Dr. Jonathan Foulds.

Scott Gilbert – From Penn State Health and Penn State College of Medicine, this is “Ask Us Anything About… Smoking and Vaping.” I’m Scott Gilbert. Smoking remains the leading cause of preventable death in the U.S., killing nearly a half-million Americans every single year. Today, in this interview, we’ll talk about the dangers of tobacco, and some strategies for quitting, but also the rising popularity of vaping — I’m sure you’ve heard of that — with Dr. Jonathan Foulds. He’s a professor of public health sciences and psychiatry at Penn State College of Medicine. Dr. Foulds, thank you for your time today. Now, I’d like to start with something that’s especially timely. I heard about a study that just came out in the last day or so. It involved an analysis of global survey data that showed that, of people who’ve tried even just one cigarette, 69% of them, or nearly 69%, went on to smoke daily. That seemed rather shocking to me. Did it shock you?

Dr. Jonathan Foulds – No. We’ve seen data like this across the globe, and the United Kingdom, where I’m from, and the United States, that’s very consistent with that. And it suggests that cigarettes are particularly an addictive form of nicotine consumption, and clearly the biggest thing is never to try a cigarette. Don’t start. If you’ve never started smoking, don’t do it. And people tend to underestimate the risk that they’re going to become addicted. So, best not to start at all.

Scott Gilbert – Is there such thing as a casual smoker? Some people say, “I only smoke when I drink,” but, I mean, is that — is that really viable?

Dr. Jonathan Foulds – No, that is a thing. Some people do that, but the risks from even occasional smoking to your health are still high, and the risks of becoming a daily, regular, addicted smoking are very high. So, you know, you don’t know if you’re going to be able to be one of those people. Most smokers become a daily smoker, so best not to even mess with that.

Scott Gilbert – Right. You’re watching “Ask Us Anything About… Smoking and Vaping” from Penn State Health, and Penn State College of Medicine. Dr. Jonathan Foulds welcomes your comments and your questions. Just add them to the comment field below this Facebook post. Whether you’re watching this video live, or if you’re watching it on playback, we can also get you answers to your questions. We know this is a very popular topic, especially this time of year. Maybe you’ve struck a new year’s resolution, that you really want to make sure that you quit smoking, or maybe a loved one has. So that’ll lead us into, I guess, a good conversation about cessation methods. What are some of the ways that — I mean, I know you’re not a clinician. You’re a researcher, but obviously, you’ve done extensive research in this area. What are some of the best ways for people to start on that path toward quitting?

Dr. Jonathan Foulds – Well, it’s very clear that the more tools you make use of in your quit attempt, the better your chances. So, for example, it’s very clear that if you get counseling, or any other kind of support — it needn’t be face to face with a counselor. It could be attending a stop-smoking group. We run one here at the med center, at the fitness center at 6:30 on a Monday evening. So you can attend one like that, which is a face-to-face support group.

Scott Gilbert – And we’ll put some information in the comment field below this post on that, 6:30 on Mondays.

Dr. Jonathan Foulds – Yep. Or, you can call a free quit line, 1-800-QUIT-NOW, or you can — and you’ll get free counseling. They’ll even call you back. Or you can go to — there’s a couple of particularly helpful websites. So smokefree.gov, that’s a CDC website that’s got lots of tools to help you quit smoking. And another one I think is a good one is Become An Ex, so it’s www.becomeanex.org. That’s also a helpful website. The next thing that very clearly helps people quit is to use an FDA-approved smoking cessation medicine. So some of them are over the counter, mainly the nicotine replacements, like the patch, the gum, the lozenge. You can get a prescription from your doctor for the nicotine nasal spray, or the nicotine inhaler. There’s also pills that you can get. So bupropion — used to be called Zyban. That helps people to quit smoking. And the one that’s good — the best evidence for helping people quit is varenicline, and the brand name is Chantix. So, you know, there’s recently been a very large trial that compared these different medicines, and found that Chantix gets the highest quit rate, compared with the others.

Scott Gilbert – So a lot of different possibilities here, especially when we’re talking about that kind of medicinal intervention. How can people get started? Because we threw a lot of options out there. Is it a good idea to talk to your family doctor?

Dr. Jonathan Foulds – Yes. If you’re thinking about using one of the prescription medicines, the best thing to do is to go and see your family doctor, tell them you’re interested in quitting, get his advice. None of these medicines have serious side effects, or serious contraindications, other than the obvious ones — you know, pregnancy, having had a recent heart attack, those kind of things. But the best thing to do is go and see your family doctor. Say you feel it’s about time to quit, and they’ll give you the best advice.

Scott Gilbert – Sounds good. And before we move on to a question that we just got, I want to ask about another kind of prong in that support mechanism, and that is other people. What about the importance of family members? And you mentioned support groups as well, but how important is that interactivity with other people in the process of trying to quit?

Dr. Jonathan Foulds – What we find is very helpful — so when we run our stop-smoking support groups, it truly is a support group. It’s not a class with me or somebody else, you know, wagging our finger. It’s really — we sit in a circle, and people share their experiences, and encourage people to stick at it. Nicotine withdrawal symptoms, which is basically a bad mood with a strong craving to smoke — they peak in the first week, and they last about a month. So having support, whether it’s family, friends or a support group, to get through that tough first month, when — you know, the getting quit part, that does help a lot.

Scott Gilbert – Yeah, and let’s be clear. Nicotine is a drug, and it is addictive.

Dr. Jonathan Foulds – Yes. Nicotine certainly is a drug. It releases dopamine in the reward center of your brain. It kind of hijacks the reward center of your brain, so that you — after you’ve been using it for a while, you don’t feel good, or even normal without it. And so when you wake up in the morning, once you become a regular smoker, your brain’s saying, “Hey, have a cigarette,” you know. And you feel restless, irritable, have poor concentration until you get a smoke. Now, once you’ve — once you’ve quit for a while, all that goes away. But getting quit is the tricky part.

Scott Gilbert – Yeah. You’re watching “Ask Us Anything… About Smoking and Vaping” from Penn State Health, and Penn State College of Medicine. Dr. Jonathan Foulds is a professor of public health sciences and psychiatry here at the College of Medicine, and he welcomes your question. We do have our first question from George, who’s touching on something we were hoping to get to, and that is about vaping. He’s asking a question I’m sure you’ve heard before, and that is, is vaping, or electronic cigarettes — is that better for you than smoking?

Dr. Jonathan Foulds – Well, we — what — the way I would put it is that vaping is almost certainly significantly less harmful than smoking cigarettes. Cigarettes contain over 7000 chemicals in the smoke. They deliver the nicotine in a high dose, which makes it more addictive. And the evidence that these are harmful to your health is very, very strong. Electronic cigarettes, in the vapor, it contains more like 10 chemicals that we can measure easily.

Scott Gilbert – Still not good.

Dr. Jonathan Foulds – Still far better to take nothing, but it’s a big step down. We’ve estimated that it’s at least 90% less harmful, just based on the quantity of toxins in the vapor, you know, and — that you get from an electronic cigarette. So just looking at the dose, and the kinds of chemicals, and the quantities of the chemicals, it seems almost certain that e-cigarettes are much less harmful. Not harmless. So nobody should be starting to use an e-cig if they’re not already smoking. I wouldn’t advise anybody to do that, and you don’t want these to be in the hands of kids, either, which is one of the concerns. But in terms of a step in the right direction, from being a smoker who’s maybe had trouble quitting, then — I’ve spoken to many people who’ve succeeded by switching to an electronic cigarette.

Scott Gilbert – We have a question from Beth. She’s asking, “What is your risk for stroke with vaping?” Is there any — is there a body of research on that?

Dr. Jonathan Foulds – There isn’t — this is the — this is the trouble, and this is why I’m couching the estimates as about, or approximately. Because e-cigarettes were only invented in the last 10, 15 years. So in this country, people only started using them, like, three or four years ago. So we don’t have the long-term epidemiology. But we know that they deliver nicotine, and we know that they deliver a few other chemicals. And nicotine itself stimulates your heart rate and so forth. So I think it’s a fair assumption that, because of the stimulant effects on the heart of nicotine, that they’ll have some effect of increasing your risk of a stroke. But whereas smoking probably doubles or triples your risk of a stroke, the effects of the nicotine from e-cigarettes is probably much less than that. It’s probably something like a 10, 15% increase. Now, you might say, “Well, where are you making these numbers up from? It sounds dodgy.” And it is an estimate. So it’s based on what we know about the increased risks of stroke from people who use smokeless tobacco. Smokeless tobacco contains nicotine in similar doses to smoking, similar doses to vaping, and we know that the magnitude of entry stress from using smokeless tobacco is detectable, but it’s much less than smoking cigarettes.

Scott Gilbert – And now, let’s talk about the so-called gateway effect. Is there any research out there that suggests that if someone has never smoked, and they started vaping, is there a danger that they could — that could lead them into smoking cigarettes?

Dr. Jonathan Foulds – Yes. There is — there are now almost a dozen studies. None of them are perfect, and as I said, this is early days in vaping research. But they do suggest that starting to use any nicotine product, you know, whether it’s smokeless tobacco, or electronic cigarettes, or a cigar, makes you more likely to later become a cigarette smoker. And that includes e-cigarettes. That’s — you know, this research is kind of tricky to do, because you can’t randomly allocate people to try e-cigarettes or not, and then follow them up and see if they do. That wouldn’t be an ethical study. So we’re left looking at people who — like, young people who try it, who have never used anything, and then they try an e-cig. Then you follow them up a year later, and see are they more likely to have smoked a cigarette. And the studies find that they are. So that’s another reason to think — no, don’t think, hey, this is safe. It’s not just water vapor and a few flavors. It actually contains an addictive drug, nicotine, and other chemicals. And we don’t yet know enough about how harmful it may be. It may be a little bit more harmful than I’m even saying, but our best estimate is that it’s not harmless, and it will be addictive. Even less addictive — we’ve published a few papers now comparing the addictiveness of electronic cigarettes and cigarettes, and it seems fairly clear that e-cigarettes are a bit less addictive. But they are addictive, nonetheless.

Scott Gilbert – I can’t help but think that, with all the talk about cigarettes, that cigars get a free pass, but yet they’re rolled-up tobacco. And how do their dangers compare to those of cigarettes?

Dr. Jonathan Foulds – Yes, well, colleagues here at Penn State — Dr. John Richie and his team have done some really good research on cigars, and shown that people absorb just as much nicotine from cigars, and just as much or even sometimes more toxicants from cigars than cigarettes.

Scott Gilbert – Is that because they don’t have a filter, possibly?

Dr. Jonathan Foulds – But many cigars do have a filter. There are cigars that we call little cigars, that are basically just the same as cigarettes. The legal definition of a cigar is tobacco wrapped in tobacco leaf. So you can buy them, and they’re just like a cigarette, except they have brown wrapper. So the wrapper is not paper. It’s tobacco leaf. And — but it’s basically a cigarette. And then you’ve got your bigger — there’s all different kinds of cigars. You’ve got your big stogies. But the evidence is fairly clear. They deliver just as many toxicants, and are just as harmful, and can be just as addictive if you inhale the smoke. So in this state, because we grow some cigar tobacco, they have gotten a bit of a free pass, in that they are taxed at a lower rate. And that’s caused people in Pennsylvania to switch to them, and that’s a concern. Don’t think they’re less harmful, because they’re not.

Scott Gilbert – You bring up an important issue there, because you’re talking about the tax rate on these kind of products. Is there any evidence to show that a higher tax has — you know, the so-called sin taxes on things like this, that they can do any good in kind of trying to dissuade people from smoking?

Dr. Jonathan Foulds – Yeah. The evidence is clear. The higher the tax, meaning the higher the price, the fewer people use them, or they reduce their consumption. So, you know, if ever there’s a budget problem in Pennsylvania, which there is every year, and politicians are looking for a way to plug the hole, then increasing the tax on all tobacco products is a good way to do it. Because it will generate revenue, and reduce smoking, and so reduce healthcare costs. It’s a win-win tax.

Scott Gilbert – You’re watching “Ask Us Anything About… Smoking and Vaping” from Penn State Health and Penn State College of Medicine. I’m Scott Gilbert. This is Dr. Jonathan Foulds. He’s a professor of public health sciences and psychiatry here, and he welcomes your questions. We’ve had some great questions, so please keep them coming. You may be a smoker with those questions, or you may even have a family member or a friend who you’re thinking, how can I get them to quit? This is a great time to put your questions and thoughts out there in the comment field below this Facebook post. You mentioned some of the research happening right here in Hershey. I’d like to ask you a bit about the Penn State Tobacco Center of Regulatory Science. That’s based here. You’re co-director, and the science that’s done there helps to inform FDA regulations, correct?

Dr. Jonathan Foulds – Yes. So that Center was funded by the National Institutes of Health, and the Food and Drug Administration. Myself, Dr. Josh Muscat, Dr. John Richie head up a group of studies that are designed to inform the Food and Drug Administration on how best to regulate tobacco products. We’ve particularly focused on the idea that the FDA could reduce — mandate a reduction in the nicotine content in cigarettes down to a really very low level. They’re not allowed to take it down to zero, but they can take it down to a non-addictive level. And the idea is that they could create a rule that would require that to be the case for all cigarette to be legally sold in this country, in which case people would be weaned off of their addiction to nicotine and cigarettes. And they would either quit smoking, or they’d switch to less harmful tobacco products.

Scott Gilbert – But I can’t ignore the elephant in the room, even though we don’t want to get political. But let’s face it. Research is not the only influence in Washington. Lobbying, as well — so there’s a lot of voices out there.

Dr. Jonathan Foulds – There are a lot of voices out there, but recently, back in July 2017, the new, you know, President-Trump-appointed Head of FDA, actually announced that they intended to go in this direction. This is the plan, to reduce the addictiveness of cigarettes, and to facilitate or make people more able to switch — who want to use nicotine, to switch to less harmful products.

Scott Gilbert – You’re watching “Ask Us Anything About… Smoking and Vaping” from Penn State Health. We welcome your questions for Dr. Jonathan Foulds, whether you’re watching this video live or on playback. Now, we’ve talked a bit about quitting, and the importance of quitting, and some of the methods for doing so. And you touched on an important issue when you mentioned that 30-day period. Can you talk about that, and how the likelihood that someone will remain — will stay away from cigarettes increases the longer that they — that they have succeeded?

Dr. Jonathan Foulds – Yeah. So we tend to split into two phases. There’s the get quit part, which is the first 30 days after your target quit day. Then there’s the stay quit part, which is after that. And the getting quit part, the first month, then this is where the medication really helps, and the social support really helps, using all the tools that I mentioned before. Staying quit is trickier, and one of the challenges we find is that people who’ve used a med — you know, a nicotine replacement, or Chantix, they’ve experienced a benefit of that. And then, within a few weeks, they think, hey, I’ve done this. You know, I’ve quit for a couple of weeks. I don’t need to keep taking the med. And they may not feel that they have the need anymore, but there’s now been randomized controlled studies done where they switch people either to the placebo med, or keep taking the active drug after they’ve gotten quit. And it’s very clear that the longer people stay on the active med, the less likely they are to relapse. So when you use a med, and you get — you go a few weeks of not smoking, you think, oh, it’s time to give up on the med, but no. We recommend that people continue on it for at least 12 weeks. That’s what the labeling says for most of these medicines. And for some of them, you can continue longer than that, if you think you may benefit from it, it may make you less likely to restart smoking. And we encourage people to take it on the longer end of that, rather than the shorter end, at least 12 weeks or longer.

Scott Gilbert – So let’s talk a bit about the social and environmental aspect of staying quit, as you would say. And that is, let’s say I — okay, I quit smoking a month or two ago, and I’m going to hang out with some friends. But we’re going to go somewhere that allows smoking, and my friends smoke. Now, what — how does that factor in?

Dr. Jonathan Foulds – Well, I think nowadays, most people, including smokers, including their friends who smoke, understand how important it is for a smoker who wants to quit — how important it is for their health. You know, it’s going to make the difference whether they live long enough to see their grandkids or not. And people understand that. I think it’s widely accepted. And we find that when a smoker speaks to their buddy, and say, “Listen, let’s go. Let’s meet up. I’d love to see you again, but I’ve recently quit. And I would appreciate it if you didn’t bring your cigarettes, or even after we’ve had a drink, you know, you don’t offer me a cigarette. Because I could be tempted.” So have a chat with your friend, or your family member, or whoever it may be. You know, we’ve recently had the holiday season, and that brings together family members and friends. Sometimes you haven’t seen each other for a while, and you get this issue of the relative who smokes. And nowadays, it’s considered totally acceptable to say, “Yeah, come around to the house. Let’s have dinner, or whatever, but we don’t smoke in our household. We have a no-smoking rule.” And when a smoker quits, that’s the time to do that, to say, “Okay, I’m quitting smoking. I’d like it to be a rule that we don’t smoke in the house anymore.” So reducing exposure to the cues as much as possible is going to reduce your risk of relapsing.

Scott Gilbert – Where are we headed in terms of trends with smoking, both for adults and for children? I’ve heard that things are headed in the right direction. Fewer people are smoking now than, say, 10 or 20 years ago, but there’s more work to be done.

Dr. Jonathan Foulds – Yes. In the United States right now, about 15% of adults are cigarette smokers. So that’s much lower. And fewer kids are smoking. There’s some people — when I tell them that, they’re surprised, say, “I seem to see a lot of people outside offices smoking.” And that’s because it does seem visible, because you can’t smoke indoors anymore. And so people have to stand outside in the cold, and it — you know, they usually stand near the doorway. But the truth is, it is coming down, and it’s going the right direction. And it won’t be that long before we cross the 10% line. Now, at that point, where 90% of the population are nonsmokers, I think it will — the change in social norms, the not smoking in public places, not smoking in workplaces, it not being socially acceptable to just light up in a car with your kids in the back, those kind of things are going to become even stronger. And that is going to become the — you know, you become a bit of a social pariah to continue to be a smoker. Many smokers tell me they already feel that way. And although it’s not a pleasant thing to be in that situation, it does create more impetus to quit, and that’s really in everybody’s best interests.

Scott Gilbert – That’s something we didn’t talk about yet, secondhand smoke, and, you know, the fact that if I’m a parent, and I’m smoking around my children, that absolutely affects them.

Dr. Jonathan Foulds – Yeah. It increases the risk of common illnesses, asthma, chest infections, those kind of things. It harms anybody who comes into contact with it. It increases the risk of — you know what, just now, we’re in January. You’ve got all the — the flu season, all those kind of things. And your risks of any of those infections are greater, even with exposure to environmental tobacco smoke.

Scott Gilbert – Okay. You’ve been watching “Ask Us Anything About… Smoking and Vaping” from Penn State Health. As we wrap things up here, we do welcome any other questions you may have for Dr. Jonathan Foulds here at the Penn State Cancer Institute. Which, although his appointment is in the College of Medicine, it’s not mistake that your office is physically located here in the Cancer Institute. Obviously, we know that smoking is a major cause of lung cancer, the number one cancer killer in this country. Any other — anything else you can share along those lines, about — because we actually didn’t — haven’t even said the words lung cancer until now. I think it’s just — it’s implied, but yet it’s something — I think it’s so important for us to drive home.

Dr. Jonathan Foulds – Yeah. I think almost all smokers are aware that smoking causes lung cancer. They may not fully understand the magnitude. So you’re about 20 times more likely to get lung cancer if you continue to smoke. Many smokers have been smoking for years. They think, well, the harm’s already done. That’s not actually the case. You know, cancer is basically where a couple of your cells go a bit wrong. They transform into cancer cell, and they multiply and create a tumor. Now, the toxicants, the carcinogens that are in cigarette smoke, they coat your lungs with every puff, and increase the chances of one of those cells going wrong and developing cancer. If it hasn’t happened yet, and you stop now, it may not happen at all. So your risks decline the — you know, they start to decline the minute you quit smoking, and so we would say that the single best you can do for your health, both for your cancer risks and your cardiovascular risk, is to quit smoking. Make a quit date, see your doctor, and get started in the road to becoming a nonsmoker.

Scott Gilbert – Some really good advice. And one more question to throw your way from Samantha here, as we wrap things up. She’s asking about secondhand vape smoke. Is it — is that harmful to those in the household?

Dr. Jonathan Foulds – That is a good question, and we all — we know that the secondhand vape, it’s not technically smoke. It’s an aerosol. So it has small particles like smoke that sometimes can trigger respiratory and cardiovascular issues, and it contains nicotine, and some of the chemicals that are in the e-liquid. So just as I get — you know, estimated for active use of e-cigarettes, the — we would estimate that the risks are significantly less than cigarette smoke, because there’s a lower concentration of chemicals in the aerosol. But it’s probably greater — it’s not just like water vapor. It’s got — there are chemicals in there, including nicotine. And so, again, I wouldn’t encourage people to vape when there’s other people around who don’t use it who’ll inhale it.

Scott Gilbert – We — I feel like we could talk about this for hours, and it’s all great information. Just one last question for you. I’m — I’ve heard people say, “Yeah, but my grandmother, she lived to be 94. She was a smoker, and she didn’t even die of lung cancer.” What do you say when people say things like that, and, you know, the possibility that smoke affects one person more than it affects another?

Dr. Jonathan Foulds – Yeah. I actually saw a movie last night with, I think, Harry Dean Stanton, a really good movie in which he’s — plays a character called Lucky. And he’s called Lucky because he’s 91, and he smokes, and he’s still healthy. But it’s such an unusual thing. We can all think of our relative who’s like that. Unfortunately, for every one relative who’s like that, we probably have five or 10 who are either suffering from smoking-caused illnesses, or have already passed away. So, you know, there are famous people — Harry Houdini, he used to tightrope-walk across Niagara Falls, and did it without falling. Doesn’t mean to say it’s a good idea.

Scott Gilbert – Not everybody should try that.

Dr. Jonathan Foulds – No, don’t try that.

Scott Gilbert – Okay. Some great information and great advice on quitting from Dr. Jonathan Foulds. Thanks a lot for your time today. I appreciate that.

Dr. Jonathan Foulds – Thank you.

Scott Gilbert – And again, you know, whether you’re watching this live or on playback, feel free to add your questions, and we will get those to Dr. Foulds. And we’ll make sure we add those to the comment field here below this Facebook post. Thank you again for your time, and thank you for watching “Ask Us Anything About… Smoking and Vaping” from Penn State Health, and Penn State College of Medicine.

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