Episode 23: Tobacco Use and Cancer Prevention: More Complicated Than You Think

Intro: [00:00:00] We are a resource for learners, including every member of the live strong cancer institutes on track educational pipeline from middle school to residency, we are a growing collection of interviews, talks and experiences, the uncover, the myths and the uncertainties of cancer and careers in cancer in order to empower and inspire generations of thinkers and leaders. This is Cancer Uncovered. An education and empowerment podcast by the live strong cancer institutes.

Kristen: Hello, this is Kristin. When with the live strong cancer institutes at UT Austin’s Dell medical school. With cancer uncovered. You probably know at this point that smoking tobacco or using tobacco products is bad for your [00:01:00] health and causes cancer. So why are there so many tobacco products still on the market? Why are people still using them? And what’s up with e-cigarettes and other tobacco? they any better? In this episode, you’ll be uncovering the myths and miscommunications in the United States around tobacco use addiction, nicotine and cancer prevention among communities of color and at-risk populations with passionate mentor, Dr.

Jas Ahluwalia. The LCI was thrilled to host Dr. Ahluwalia as the keynote speaker for our recent cancer prevention and control symposium in the spring of 2022, which was a day full of experts talking about their research into the many ways to stop cancer specific populations and how clinicians and researchers can work together to improve health outcomes, and quality of life for their patients. Now we’ll welcome, Dr. Allwell. 

Jas: Yes. [00:02:00] The Jas Ahluwalia I’m an immigrant came to this country, uh, 58 years ago. So I came and I was one year old. I’m a professor of behavioral and social sciences at brown school of public health, and also a professor at the brown university medical school. Uh, I’ve been in academics for 30 years, having been at Emory university and a department chair at university of Kansas, then at university of Minnesota and briefly Dean of the school of public health at Rutgers university. And again, at brown for the last four and a half years. Uh, my work has been on nicotine and tobacco and minority health for, uh, for those, uh, three decades. Fantastic. Well, thank you for taking the time. How did you end up doing what you’re doing now? How did you get here? So what happened was, um, when I was a resident in internal medicine resident at university of North Carolina at chapel hill, I had to do a project like everyone did. So many of my colleagues did things on heart disease and kidney disease. And I sort of was trained [00:03:00] differently as an undergrad. I took courses like sociology of illness, politics of health, um, ethics and medical care. So that just sort of taking a different path if you will. So I spoke on what I saw as a leading cause of morbidity and mortality, which is diseases. Uh, which was tobacco. So I gave a talk on smoking cessation, which many people view as sort of weak science, if you will. Uh, but if it’s a leading cause of death as a physician, I should be addressing it. And then what happened was, um, fast forward, uh, to my fellowship at Harvard, I took a class on clinical trials. A certain kind of research study. And from there, my first job in 1992 was at Emory university, but I was based not on the main campus, which is gorgeous, but base downtown in urban Atlanta at Grady hospital, which is a large safety net hospital for the underserved, the uninsured and largely minority community.

So about 90%, [00:04:00] 80% of the patients at Grady were African-American. And when I noticed when I was a physician on the inpatient setting, that people were coming in for one to five reasons, um, to the hospital, alcohol, poor diet, physical inactivity, um, maybe substance use. And part that I was very interested in is a tobacco immediate.

It’s a leading cause of death in the United States. And soon to be in the world. 

Kristen: Dr. Ahluwalia, can you say more about minorities and tobacco?

Jas: Yeah, absolutely. No. The tobacco industry is, is a very interesting industry. It evolved in the late 18 hundreds and rapidly expanded in the early 19 hundreds. And at that time, and I’m not here to defend that industry, but clearly in that time, people were not actually aware that tobacco was dangerous. In fact, physicians were prescribing tobacco. To treat what is then was then called [00:05:00] Qatar. It’s just a great word. C a T a R R H I bleed, which effectually is known as cold in the head. So if you’ve got a cold that you would use tobacco in one form or the other to treat it, and there was no sense it was dangerous. It wasn’t really until the 2030s, maybe a hint. And then the forties, fifties, when some big studies were done by some, uh, scientists and physicians here in the U S. The famous study in England to show that in fact cigarettes caused lung cancer and disease. So what happened is the industry targeted different populations through time. And, um, somewhere mid century, there were targeting African-Americans with cigarettes.

Cause they viewed that as an opportunity to make more money. Um, and then they expanded into the area of menthol cigarettes. And so that’s why today we see that 80% of African-Americans smoke, menthol cigarettes, 50% of Hispanics. Menthol cigarettes and only [00:06:00] 20% of white smoke mental cigarettes. So it’s really a legacy of marketing.

I mean, marketing, if everyone requests does marketing work, it works. It works very well. In fact, As some of us know from the front page of the papers yesterday, it was a huge announcement. Uh, here we are in April, 2022, that the FDA is moving forward with the proposed rulemaking to ban menthol in cigarettes and cigars, which is definitely something that is a long-term. Additionally menthol has a big marketing component to it. Often when you look at ads for menthol they’re green, which represents health, which represents money, which represents Greenlight means go when you’re, when you’re at a red light or green light. Um, and I think it connotes a lot of positive imagery and so there’s a huge psychological component as well. Um, so I think, you know, there is a long history of. [00:07:00] And, you know, the tobacco industry, which the executives were of course, largely white men. And, um, and that’s sort of some of the history now, the industry is changing dramatically in the sense that they want to get out of the business of killing people and getting out of combustible cigarettes.

So they’re moving into these, what are called novel nicotine products or harm reduction products. And the CEOs, you know, will go at their annual shareholder meeting. And when they’re interviewed by the New York times or when they rarely are willing to go on TV, they will say, we want to get out of the business of combustible cigarettes, tobacco leaf, when it’s processed have literally four and a half thousand chemicals in it. And probably about 50 to 60 of those chemicals are. Causing agents. So they’re called tumor accelerators, carcinogens carcinogens. So either president loan, they cause cancer or in the presence of another chemical they’re accelerated to cause cancer. That’s pretty dangerous stuff. And in today’s world, if tobacco appeared in the market, we knew this.

It would never be legal. [00:08:00] Like people always say, why can’t we ban tobacco? Why can’t we ban the industry? Why can’t we ban. Because there’s a long history of 150 years, and it’s very complicated. People say, why does it have to be complicated? Because it is, uh, but if it did come on the market today, it would never pass muster.

And because we knew about it, right? Because remember I said that we didn’t know it was dangerous in 1900, so it comes to market and then you learn about it. You know, it’s very clear that tobacco causes cancer. And when it’s combusted, that means you light it up. You know, the tip of a cigarette reaches about 800 degrees Fahrenheit.

Uh, you know, it’s hotter than hot. Um, in fact, cigarettes are the leading cause of fire, uh, deaths in this country, which is a very strange statistic. People falling asleep while they’re smoking and things of that nature. But when you combust tobacco? it, it actually releases a lot of these cartoons. Because when you use smokeless tobacco, especially the smokers tobacco in this country, like school and other dip into tobaccos, [00:09:00] it’s less. Now it’s a tricky thing to say less dangerous. It causes different kinds of cancer. Like smoke was tends to be related to head neck and mouth and oral cancer. And combustible of course is linked to lung primarily, but actually is linked to Safa dual cancer, uh, genital urinary cancer, which means the. And the urinary tract, it’s actually to a lot of cancers.

Now, nicotine is one of the four and a half thousand chemicals. It is in fact, the agent that is responsible primarily we believe for the addiction property. So the brain has all these receptors that bind nicotine, like billions of receptors. And you can fill them up with this nicotine from cigarettes. And when you do it activates a lot of neurotransmitters, like serotonin. Dopamine or epinephrin makes smokers feel relaxed, less stressed. They feel good. to remember as scientists and physicians that people slope, because it makes them feel [00:10:00] better. so we can’t judge them. We can’t change. Um, we have to actually have a support for the fact that they’re doing something that in the current time makes them feel better. But in the long-term of course it’s not good, but it’s key to remember that nicotine does not cause cancer and that’s going to become very important. And over the next 5, 10, 15 years, sadly, when surveys are done of us physicians, about 60% of American physicians, believe nicotine causes. So why does that matter? It’s going to matter because when you get to these alternative nicotine products, um, uh, it gets into that. And I suspect you’re going to want to talk more about. 

Kristen: Absolutely. So I actually, speaking of that, I’m going to turn it over to my colleague, Eric, who works with our department, uh, at the live strong cancer institutes. And Eric had a question regarding e-cigarettes. So go ahead, Eric.

Eric: Hello, my name is Eric Deleon and I’m a junior here at UT. Um, I kind of wanted to ask. [00:11:00] The cigarettes, uh, would you say that they really offer a safer alternative alternative to nicotine use as it’s often claimed compared to combustible tobacco products?

Jas: No, that’s the million dollar question. So these things came to market about, uh, about 10 years ago, plus or minus, and really took off about six, seven years ago. And they go through different ways. You know, Juul came out strong and rapidly, became set death, 70% of the market. Like a monopoly, but the guys who founded Juul, these two guys who I think had gone to Stanford really had a good idea in mind when they did this, one of them, their father smoked and had smoking disease. They were really wanting an alternative that was smoker. So that a good agenda. Well, I think what happened is like anything out of Silicon valley or high tech, and then you get investors involved and you get people who want to make money. And so their, their agenda got sides sidetracked into making money.

[00:12:00] And the way you make money is you market like crazy. And that happened. And so right away, e-cigarettes got a bad name because then what happened is in this country, youth began to take it up because youth like technology, youth, Respond to marketing when their sex appeal and young models and cool people, especially if you get, um, uh, I’m not a social media person, but when, when you get influencers, that’s what they’re called.

You get influencers involved. I mean, it’s sort of a whole other world when I grew up. And so that sort of, uh, you know, changed things a lot. And so the agenda of a safer alternative could never be met when it started, got out of the way by the fact that. We’re using it at astronomical rates in the peak at about 27% of people, less than age 18 high school students actually were using an e-cigarette at least one, one day, uh, in the, in the past 30 days that has fallen rapidly.

And that of course is [00:13:00] good. But when you look at the science behind, it always think about that things innovate. So the first-generation e-cig, we’re pretty simple, not great products. And we went to second generation. Third generation. And for the last 5, 6, 7 years, we’ve been at fourth generation. Things that some of you, our listeners may know as jewel or ACE is enjoys product or ruse, which is rentals, tobacco product. Some of these products are made by companies that are tobacco companies like booze. Some of them are made by companies that have a partial, uh, investment from a tobacco company like Juul. And some are, uh, what I call pure play companies like, uh, And the science behind it is that they are safer, but they’re not safe. So the companies themselves will tell you that e-cigarettes are not safe. And that’s important to remember, but are they [00:14:00] safer than combustible safe? I have to say that with the knowledge that we have today to keeps getting stronger over each year, goes by that they’re dramatically safer. The United Kingdom uses a number, which is pretty impressive that they’re 95% safer than cigarettes. You know, people have questioned that number. And to me, whether it’s 95% or 80%, even if it was 75%. It’s the classic argument about harm reduction, which applies to seatbelts helmets. Um, how much cake you should eat if you have diabetes or heart disease, should you know, and then in the world of substance use about methadone in view for, uh, opioid addiction or, or even more controversial, uh, needle exchange or even more controversial. Is medically supervised needle exchange sites. In other words, where that nurses are actually on staff to assist in the [00:15:00] injection of drugs. I mean, this is very radical, but there’s some countries, you know, in Amsterdam and very progressive companies are doing things like this because it’s really about this concept of harm reduction.

And so you can apply those same principles of harm reduction. Um, to the field of tobacco, I have a theory as to why maybe scientists and the American public may not embrace it as much for tobacco. And I think it’s linked to the tobacco industry. See, there’s no real opioid industry per se. There’s no other, other industries like this.

So the tobacco industry, people just focus on that. They lie. They’ve manipulated. They’re evil. They’re even Hollywood movies made about it. And people just keep remembering that. But as a physician, I have to remember the individual and at the pot as a population health scientist, as a public health scientist, I also have to remember the population.

And what it says is that for the individual, if I can, if they can’t quit cigarettes, but I can get them to something [00:16:00] that’s at least safer. And then eventually they can get off that so-called safer project. I should do that. And the big news is. This week, there were again, as I mentioned, two huge FDA announcements, one about menthol, but also a news that some of you may not have heard about as much, which is that the FDA is now granting what are called P MTAs pre-market tobacco authorizations. And what they’re being given for is if any tobacco product wants to come to market today, even a different cigarettes. We had a variation of a cigarette, a low nicotine cigarette, a safer cigarette. They cannot bring it to market bus without going to the FDA and getting it authorized, which is not a simple procedure, requires a lot of science behind it. And you can only get a PMTA that a couple of bullet points that are principles. But in general, if you can show that bringing the product to market will improve the health of the public. That the [00:17:00] public health of people in the us will be improved this product coming to market. So you can imagine with many new cigarettes, that’s not going to happen, if you come with nicotine pouches or e-cigs. You potentially can do that. And so about mid April, the FDA authorized, not approved cause approved implies that it’s safe, but authorized the marketing of, ACE ACE, which is an enjoy product as the first sort of fourth generation state-of-the-art e-cigarette has been granted the PMT. So in my opinion, to train his left, to stay. Harm reduction and tobacco’s hair to say stay I’m celebrating that because I think this is a potential game changer. A colleague. He emailed me yesterday and said, uh, from Seattle that, uh, you know, hopefully in our lifetime go see a smoke-free society. I wrote back and told [00:18:00] him that, um, you know, while some people say when the smoking rates are less than 5%, you sort of in essence, have a smoke free society.

Cause it’s never going to get to zero. People will always smoke something, but that I actually view in 10 to 15 years, By the year, what’s that about 10. So 20, 20, 20, 35, that we will be less than 5% prevalence in United States. And I think these novel nicotine products?

like e-cigarettes and things like that will be part of that. 

Kristen: Your work is around minorities and tobacco use and cessation. Right? So when you talk about the work that you’re doing is. Hoping that people move to e-cigs and then eventually using, know, nicotine and everything else. How, how is that going? Is that working? Are, are and women of color switching to e-cigarettes and, and are they, what does that look like?[00:19:00] 

Jas: Well, I think what would be on record repeatedly saying the following. If you don’t use tobacco. Don’t start. If you use tobacco and cigarettes, quit use FDA approved medications, nicotine gum, nicotine patch for in the clean buproprion Chantix, I, them, you know, different. They go under different names to try to quit, try quitting cold Turkey. If you cannot quit. And you’ve tried since. Then moving to these so-called alternative nicotine products, like e-cigarettes is a good thing. So I think I just want to get that on record, and it’s really important that listeners hear that of loud and clear. I think it’s a game changer because if the goal is to eliminate disparities to Saturday is just a difference, right?

Between X and Y. You subtract two and you see what you have. And if you look at who smoked cigarettes in the United States, right now, it can be summed up in sort of like? three to 500. Low [00:20:00] socioeconomic status, communities, people with significant mental health disorders, like schizophrenia, severe depression, anxiety disorders, people who have alcohol, uh, disorder, alcohol use disorder, or alcoholism, high rates of smoking. And finally people with opioid use disorders, also high rates of smoking. If you think about it, it’s, it appears to all be either minority groups or vulnerable groups. And, and, and if we’re gonna make a dent in improving the life of Americans as whole, because these are all Americans that I just named these groups, we have to make progress. And so, again, as I said, the message is quitting, but if they can getting folks to these other products, How’s it going well, it’s tricky because unlike the UK was that a lot of misinformation and, um, and since podcasts are about communication and you’re a communication expert is that, [00:21:00] um, the misinformation is doing that. Uh, people think, um, nicotine causes cancer, you both think e-cigarettes are as, or more dangerous in cigarettes. I mean that the chances that are about zero, I mean, one of the concerns that people have with the semi valid is we don’t know the longterm effects of e-cigarettes, but we don’t know the longterm effects of many things that get FDA approved for marketing to treat. Um, because we truly don’t want minority communities to start using these. And it turns out. That they’re actually worse than we thought. Right. But on the other hand, if they’re not, we surely want these committees not to be less behind because they also do tend to be late adopters of technology because of cost issues, reimbursement, communication, and miscommunication, and so on and so forth.

Yeah. Okay. 

Kristen: Uh, other than e-cigarettes are there other novel nicotine products?

Jas: You know, interestingly enough, there are, and it’s important to [00:22:00] understand the differences. So let me just say sort of the three category. So to these e-cigs. Which use a heating source of battery to heat, a liquid with gently. It’s pretty simple liquid it’s water, nicotine, and something called PG and VG prosecuted.

Uh, I don’t remember the names, but they’re actually found in food, PG and VG are found in food to eat it. And it’s very safe. It was very important for our young listeners who are high school students that undergraduates. How the route of administration of a particular chemical determines its safety. So PG and VG when you eat it, which we do every day probably is safe. But when you end to heal it, it becomes a little different. So that’s some of the components of e-cigarettes that might be less, less safe. There are other products, there’s something called nicotine pouch, which is taking off these products? go into the trade names of Zen. Uh, on with an exclamation point. Um, and there’s a few more in this country that, uh, they’re doing well. And it’s just enough. You would think [00:23:00] that this is kind of product that smokeless tobacco would like, which they do because it goes into your mouth and then you leave there about 50 minutes and you take it out. It’s a very small pouch and it just says nicotine. And you would think smokers wouldn’t necessarily want it, but smokers are also taking it up in suits from clinical studies done, and we’re actually doing a study right now. It does appear that smokers can get off their cigarettes completely and onto these pouches, just like they can release cigarettes. And I’ve actually read some of the papers done on these pouches, the biochemical profile of the pouches nicotine. He is almost the exact same as nicotine gum, which has been around for 30 years and is FDA approved as a medication. So that should tell you that pouches pretty darn safe. Not something we can say as much about e-cigarettes, but for couches, we can’t now of course, again, There is nicotine in it.

So let’s understand that, um, nicotine has its, its so-called risks, but they’re pretty [00:24:00] small for some of these smoke cigarettes. There’s another product that was on the market briefly, but the hat come off the market because of patent suits, but it’s going to come back on. People didn’t know about it because it is going to come back. It’s called ECOS. Um, uh, it’s a heat, not burn product H and B. And what it is is it’s modified tobacco that goes in a stick that looks like a cigarette. It looks exactly like a cigarette and you put it in a device that looks like the size eyes a bit about, about smaller than the iPhone a little bit. And you put the cigarette stick inside. And What it does is a battery operated device. Like the iPhone heats the stick to about 300 degrees centigrade or possibly Fahrenheit. I can’t remember, but it gets hot above boiling, but it doesn’t combust the tobacco. It heats it. Cause when you combust things, combust means to light on fire. Um, then there’s more generation [00:25:00] of, uh, bad chemicals.

So by heating it and doing a modified tobacco. These I close or heat sticks or heat, not burn is about 90% safer in the chemical analysis or hired 95% than the cigarette. So the way I think about it is these not burned. Are definitely say for them, cigarettes are probably, maybe not as safe as an e-cigarette, but not too far away from it. And it will take off in Japan. There’s been a massive switch from combustible cigarettes to this I close and I predicted 20 years. We’re going to see a rapid fall of cancer, death and chronic obstructive pulmonary disease in Japan.

Kristen: What words of wisdom do you have for our listeners who are interested in being future healthcare providers, future health? Yes. 

Jas: I wouldn’t say one is again, let science [00:26:00] inform policy. That’s sort of when, as you grew up and you think about that. Second is as you are a student, a high school student and undergraduate the medical students and nursing students, dentists always look at things with a inquisitive. And, and, and question everything. So, um, even the stuff that I sent today, look it up, Google it, read stuff, out more about read books about it and sort of get at what is the truth. There’s a lot of misinformation in this world. There are a lot of agendas. Corporate America has an agenda, which is to make. And deliver it to their shareholders. Hopefully physicians have an agenda to take care of their patients. Public health scientists have an agenda to improve the health of the public. So there’s all these competing agendas and the government has an agenda hard to understand sometimes, but sort of really question things and come to your own conclusion based on what’s out there. what’s scientific. I would also say that follow your [00:27:00] passion. You know, what puts firing your. Yeah. When you wake up in the morning, gets you excited? You want to sort of a hands-on health care provider? you know, the profession that provides the most direct patient and direction is actually nursing. Do you want to be a scientist who also sees patients, you know, then you can be a physician in a medical school, so you can do both. Do you like teaching? Do you want, do you want to teach students a lot, then maybe get a PhD and do that. It’s all. Really important stuff. And the final thought is we work best in teams. And I think the problem is, we live our silos, you know, physician. Uh, silent, uh, social workers, asylum, does their thing, but the best way to solve the complex problems of the world or the complex problem of an individual patient is to sort of work in a team. So if you’re working with a patient [00:28:00] let’s say has cancer and can’t afford their medications, their hospitalization, then that’s to go back to the outpatient and take a pill for 16. What Is the reimbursement scheme? What’s their social support at home? Do they need physical therapy? Do they need occupational therapy? How will they get transportation to their doctor’s appointments? that sort of at the individual level and the population level, wanted to solve things like poverty, which is of course so much relate to health and things like that, it’s not one person or one profession that will do it. It’s economists sociologists, psychologists, physicians. So learn to think and work in teams. I love that.

Kristen: Is there anything else? would like to add or something I should have asked and I didn’t. 

Jas: Yeah, I would say if we want country to be great we want to do what is best for our fellow human beings, a society will always be judged is how is it taking care of those [00:29:00] that are less fortunate and less able to provide for themselves? So this means often the low. A socioeconomic status groups, people who live in poverty or the extreme is homeless people. And as that, you know, what can we do to to contribute, to making their lives better? 

Kristen: Thank you to Dr. Jas. Ahluwalia for sharing your time and expert. If you have

Intro: Um, 

Kristen: or an idea about a future episode, please email us@livestrongcancerinstitutesatdellmeddotutexas.edu. To find out more about the live strong cancer institutes, please visit Dell med dot U, texas.edu. Please also follow our department chair, Dr.

Gale Eckhardt on Twitter at. Gale Eckhardt Eckhardt E C K H a R D T. This is Kristin when with the live strong cancer institutes and cancer [00:30:00] uncovered an education and empowerment podcast, challenging you to keep asking questions to stay curious. Thank you for listening and learning with us.

We’ll see you next month.