Smoking is still on fire & deadly, even though for so many, tobacco smoking seems like a practice of the past. After all, the percentage of people smoking has declined sharply in the last 50 years. The whole idea is further removed from the country’s collective mindset because puffing away on a cigarette, cigar or pipe is now banned in so many places. And, of course, the days of the Marlboro Man and other tobacco-related advertising is only a distant memory. Ultimately, it’s easy to think tobacco use and smoking have been whipped. Unfortunately, they haven’t. Tens of millions of Americans continue puffing away and hundreds of thousands still die annually from the related consequences. Worse yet, the new flood of tobacco products hitting the market threatens to put a new generation at risk from the perils of tobacco. All this begs the question of whether the tobacco scourge can finally and completely be put to rest. Jennifer Folkenroth of the American Lung Association has some answers. She recently spoke to WellWell about what can and should be done and why it is so hard to completely stamp out smoking. Read on.
Smoking has been down to its lowest level nationwide since 1965. Is that accurate and why has this happened?
That is correct. Cigarette smoking has declined by more than 70 percent since 1965, which is great news. However, cigarette smoking among all U.S. adults continues. So, although we’ve seen that decline, we still have about 470,000 deaths attributed directly to cigarette smoking every single year, as well as an additional 19,000 individuals dying from secondhand smoke exposure. This is just since 2006. So, although we’ve seen a downward trend, we still do have individuals who are being impacted and continue to smoke.
What has really contributed towards that successful decline in reducing smoking across the United States is the increase in public awareness of the harmful effects of smoking, increased access to cessation programs that are helping individuals to quit and mass media campaigns to help change the public’s perception of smoking. We also have fewer young people today who are starting to smoke cigarettes than what we’ve experienced in past decades. We have increases in tobacco product prices, which have helped with encouraging individuals to quit by implementing smoke-free air policies at state and federal levels, eliminating flavored tobacco products has certainly made an impact, and having more comprehensive tobacco cessation coverage benefits. So that’s just making sure that insurance companies are helping to cover counseling plus medication for those folks who want to quit, as well as the development and launch of the American Lung Association’s State of Tobacco Control Report, which helped provide states and those lawmakers with the tools necessary to implement the strongest policies possible to protect Americans against the tobacco industry’s influences.
Do you see this reversal, this decline in smoking as inevitable?
No, despite notable progress as highlighted in the recently released Surgeon General’s report, there are still some populations where smoking and exposure to secondhand smoke continue to persist. Since 2000, tobacco use has disproportionately impacted the health and well-being of specific vulnerable populations, such as residents of rural areas, military veterans, LGBTQI plus individuals, adults who do not graduate from high school, low-income earners, uninsured persons, communities of color, persons suffering from a mental health and substance use disorder and adults living in public housing. We are seeing these populations still making smoking a very relevant public health crisis that continues to shine a spotlight on and work to find equality. There are still way too many people who continue to suffer from the devastating effects of tobacco use. And this is certainly a public health crisis we need to keep very relevant.
Why are some groups and demographics more susceptible to smoking?
One of the largest reasons is they are targeted by the tobacco industry in their marketing tactics. They know that communities of color are particularly vulnerable to addiction and the physiological pathways within the body are more susceptible to the addiction itself. So, they play off of this through tobacco industry marketing through tobacco retail placement, even making sure that if you take a look at some of these communities of color, the likelihood and number of tobacco convenience stores and point of sale advertising occurring at these gas stations and convenience stores are tenfold in comparison to those that you see in, let’s say a predominantly Caucasian community. So, they are blatantly being targeted. In addition to the tobacco industry, we are seeing the socio-cultural circumstances of these individuals, the high stress that is occurring with LGBT plus communities and the lack of culturally competent healthcare being provided to communities of color or individuals with lower income. There are certainly disparities that exist that are not setting these individuals up for success in living tobacco-free lives.
Is smoking becoming an overlooked danger in America? Do people assume it’s no longer a major concern?
Yes, despite the gains, tobacco use remains the leading cause of preventable death and disease nationwide. It is accounting for more deaths than alcohol, AIDS, vehicle fatalities, illegal drugs, murders and suicides all combined every single year. In the United States, 11.6 percent of adults currently smoke. That’s 28.8 million people and 10.1 percent of our high school students. That’s representing 1.58 million students. We feel that now that the perception of harm and the understanding of the impact on our health are known, this is something that no longer needs to be a priority. And that simply is not the case.
Is tobacco use having a greater impact on people’s health today because of increased rates of obesity, lack of exercise and overall declining health?
I could certainly say that lifestyle factors can come into play into how the body can repair, as well as the intensity and frequency that this product, in particular, can damage and or evolve and mutate cell growth for cancers. However, one thing I always like to keep in mind is tobacco is a unique legal consumer product. It is the only one that kills half of its users when consumed as directed. So, when you’re dealing with a product of this lethal magnitude, in all honesty, it doesn’t matter how healthy or unhealthy an individual is, the health risks are so significantly harmful, that even the healthiest of individuals can see a significant risk associated with using these products. We’re also really watching a trend right now of dual use with tobacco products. And that truly is years and decades ago, you smoked or you didn’t smoke, but very rarely did you use multiple tobacco products, smoking and then while you’re at work having a wad of chew and then in the car, vaping. Today, we are seeing so much dual use and poly use that we didn’t see in past decades. So even though those individuals who smoke are not as prevalent, those who tend to use multiple products are. So, we’re even further compounding the unhealthy impact taking place.
Can you outline a little bit more of the other tobacco uses that people may not think about if you’re not into tobacco or around people using it?
A variety of different tobacco products that exist are cigarettes, and cigars, including both the small mini cigars like cigarillos, as well as the larger cigars that we may be more familiar with. Pipe tobacco still is very prevalent. Smokeless tobacco or chew. We’ve got the hookah or water pipe, which wasn’t very popular, but now you’re seeing a lot of hookah bars pop up, particularly in college towns, a social spot for folks to come together. E-cigarettes and vaping devices. And there are so many; there are six different types of these E-cigarettes and vaping devices with over 460 brands out on the market. This includes tanks, mods, rechargeable, disposable and refillable. But in addition to these, there are also nicotine pouches. These are oral pouches that have synthetic nicotine in the actual pouch that you tuck between your cheek and your gum and it delivers nicotine through the system. That is our newest product on the market. In addition to what’s called Snus. This is a smokeless spitless packet. It is derived directly from the tobacco leaf and still has some tobacco in it. So, the difference between a Snus pouch is that it would be brown in color and have that tobacco leaf. The newest version, these new oral nicotine pouches are completely clear and discreet, derive the nicotine either synthetically and lab-based or directly from the tobacco plant for individuals to be able to use these products undetected.
Do these all contain tobacco products or just some of them?
The majority of these products do contain nicotine and research studies have even shown that even those that say zero milligrams of nicotine are finding traces of nicotine within those products. The FDA is currently working on regulating and reviewing applications of these products to truly find out what is in them. But it’s an incredibly lengthy process and it’s going to take them quite some time to get through all of the applications that have been submitted. But yes, we are finding that these e-cigarette and vaping devices, in addition to nicotine, also have other harmful chemicals detected, including propylene glycol and vegetable glycerin, acrolein. These are all chemicals that we know can cause irreversible lung damage.
Are people aware that vaping and e-cigarettes contain products or do they assume they’re safe?
Yes, it is one of the biggest misconceptions. A lot of individuals feel that puffing on an e-cigarette or vaping device is just water vapor, harmless water vapor, when in fact it is not. It is a chemical-filled aerosol that is being inhaled by the primary user as well as secondarily by all individuals around you. It’s incredibly problematic and a huge misconception. It’s not just water vapor as folks think, it’s full of chemicals.
Is there anything the government can do to put greater restrictions on tobacco?
Yes, we have gone through the flavor restrictions that have taken place. However, unfortunately, there was a loophole included in this where disposable e-cigarette and vaping products were exempt. Therefore, you’re seeing a lot of young folks who are using these products and sticking with the disposable because they come in kid-friendly fruit flavors and we also know that the FDA, although they are working very hard to get through the applications to truly understand the harmful impacts for the risks versus benefits to using these products, that the process is so very long and daunting that it may be years before we truly know what is in these products. Until then, they truly are being sold on the market illegally. They are not authorized by the FDA to be marketed and sold here in the United States.
Smoking is most frequently associated with lung cancer. What are the other dangers of smoking?
When we think of smoking cigarettes, we think of our lungs, we think of lung health. In fact, smoking affects everywhere your blood flows throughout your body by nicotine and over 7,000 chemicals and toxic compounds that are in cigarette smoke flow through the bloodstream throughout the entire body. This means that cigarette smoking can directly lead to increased risks of 12 different types of cancer, cardiovascular disease, coronary heart disease, stroke and heart attacks and chronic obstructive pulmonary disease or COPD. We’ve got poor reproductive health outcomes that are documented and the rate of heart diseases in particular, stroke, emphysema, lifelong health impacts on infants that stem from smoking-related preterm deliveries, stillbirths and low birth weight. But then there is a whole list of health consequences outside of that due to secondhand smoke and individuals who are just in the environment around their loved ones as they are smoking.
Exposure to secondhand smoke in itself poses its own serious health risks like heart disease, lung cancer, stroke, asthma attacks, bronchitis, pneumonia and SIDS among children. And then in addition to that, not just talking about cigarettes, but what about some of the oral products as well? What about chewing tobacco? This is when we start to see an increase in oral and esophageal cancer, periodontal disease, tooth loss, dental caries and staining of teeth. So, it depends on what product you’re using and how that product is taken into the body. But we are seeing basically from the beginning anywhere your blood flows, you can be impacted by tobacco use.
Is there progress being made in the ability to help people kick the habit?
There’s always so much more that needs to be done. And I’m a certified tobacco treatment specialist and I’ve been treating folks and providing quit programs for over 20 years now. The hopeful news is people want to quit. Research shows that over 70 percent of individuals who smoke want to quit and about half will make a quit attempt each and every year. Now, whether that be going three hours cold turkey and getting through a weekend as their definition of a quit attempt, which we absolutely commend any type of quit attempt, or those that seek treatment and quit longer term.
Of the 28.8 million U.S. adults who smoke cigarettes, unfortunately, of the half that try to quit, only about 8 to 9 percent are successful. This is because the majority are not using evidence-based, proven effective cessation strategies. That would include our FDA-approved cessation medication plus counseling, so behavioral counseling, whether that be by the phone, one-on-one or in a group setting. We know that these two combos, medication plus counseling, increase an individual’s success rate in finally being abstinent from tobacco products. One other area too, even though we are making progress in the amount of coverage that insurance companies are including, is the benefit of helping to support individuals through paying for that FDA-approved cessation medication, for helping to pay for that counseling. We’re definitely seeing progress there, but there is still a lot to be made.
At the end of the day, if there’s one thing that I really wish we could make more significant progress on in helping folks to quit, this would be clinicians giving advice to their patients on quitting smoking, as well as helping them by connecting them with a service, giving them that greater impact of a higher successful quit attempt. Unfortunately, we are finding that fewer than 40 percent of individuals who are speaking with their primary care provider are actually being asked, advised to quit and then referred to a program to assist them. In all honesty, this should be a standard practice of care. Anytime I go to the doctor, if I am a smoker, I should be provided with services just as I would for my blood pressure, for my diabetes and any other chronic relapsing condition. And unfortunately, we’re just not there in our health systems today.
When you talk to your clients about tobacco treatment options, what feedback from patients do you get that surprises you?
What surprises me is how much importance they place on a scaling system and quitting smoking, yet they rate their confidence and ability to quit so low. And seeing that confidence increase when provided with the tools that are evidence-based and proven effective. I would also say the lengths to which individuals go to hide and protect this dependency and or addiction and how many folks want to quit alone without anyone knowing. I am an ex-smoker myself. I was a smoker for nine and a half years and was diagnosed with cervical cancer in my early twenties. They said I had to quit to get the surgery. I was an angry quitter because I felt like I was being forced to do so, but didn’t really want to. For me, I also was what I would consider a closet quitter. I didn’t want anyone to know I was making a quit attempt because I figured if I failed, I wouldn’t disappoint anyone. And I think a lot of my clients feel that same way. They don’t want to recruit their family and friends and enroll in a program to quit. They want to do it cold turkey. They want to do it alone. And unfortunately, it’s resulting in unsuccessful quit attempts and a relapse right back into smoking. I advise folks to tell everyone you’re quitting. A quarterback does not score on his own. He’s got an entire team behind him making those points and those plays. Quitting smoking is no different. You want to recruit as many folks for your team as possible to be successful. And who cares if you slip or relapse? It’s probable. Research shows that your likelihood of relapsing on a lifelong dependency may happen and that’s okay.
Why is it so hard to quit smoking? There are programs to assist. Is it that people aren’t aware that this is how you go about quitting?
Yes. These folks don’t realize the magnitude of the challenges that come along with quitting. They hear what society says and that it’s a bad habit, just break it. When in fact the majority of society doesn’t understand what it feels like to be hooked on nicotine and what it feels like to try to stop doing something that you’ve done 1.5 million times over the last 20 years. I see tons of light bulbs go off among my clients when I explain to them the three-link chain of addiction that occurs in smokers. And I’ll give it to you simple and straightforward. There’s the mental challenge. It’s the one that tells you it’s your best friend. It’s your break from work. It’s your break from the crazy kids or grandkids. It’s your reward after a project is completed. It’s the one thing that is for you and you alone, your one vice. That, in itself, comes with its own challenges when quitting. You start feeling lonely, you feel like you’ve taken away your best friend. You feel like you don’t have those breaks anymore. So, there are the mental challenges of quitting.
Then there’s the physical, which we all think of first and foremost. That is taking a puff off of a cigarette, nicotine, stimulating the alpha-4-beta-2 receptors in the brain, releasing that happy feel-good chemical dopamine. That is just the physical effect. The third one really is sociocultural or social. This is the one that is associated with triggers. I get in the car, I light a cigarette. I close down the laptop, I have a cigarette. I hang out with my friends, I have a cigarette. In fact, folks relate quitting with I just stopped doing something. Well, no, in fact, you have learned and triggered behaviors that you have acquired over 20-plus years that now need a plan in place. For those individuals, they say, OK, the physical effect. OK, I’d smack a patch on my arm or a pop of nicotine gum. But they are only addressing one out of all three areas of that addiction. So, you’re right. They don’t know. They think that they should be able just to quit cold turkey. And what happens is these three different challenges compound them day after day.
Is there less danger with smoking a pipe versus a cigar versus a cigarette or vaping?
It comes down to how the product is used. If you were to ask me about every single tobacco product on the market, which is the most harmful? I could very clearly give you the answer that it’s cigarette smoking. And that really comes down to the over 7,000 chemicals and toxic poisons and the fact that we’re lighting it on fire too. You can take a cigarette and put it in a beaker of water and see there may be 2000 chemicals, but when you light those chemicals on fire, you’re actually creating over 7,000. So, the carcinogenic effect certainly increases those health impacts. When it comes to e-cigarettes in particular, they’ve only been in utilization here in the United States for just over a decade. We still are unaware of the long-term health impacts of these products. There’s still so much research that needs to take place. However, we are preliminarily seeing what the impact of these products are having on health. And I will say that for e-cigarettes we are seeing lung damage. We are seeing higher susceptibility to respiratory illnesses and diseases. We are seeing a skewing of brain development among adolescents whose brains are still developing up until age 25. So, the perceived harm and risk associated with each of the products does vary and many times comes down to how those products are used and were intended to be used by the manufacturer. However, every single one comes with some level of risk.
The American Lung Association does a tremendous amount of good work. Are there programs and resources that you want to highlight?
Yes. And I don’t want to give just one area of resources, mostly because in order to end tobacco and nicotine use, it truly is necessary for an entire community approach to this. We all need to be involved. This includes lawmakers, parents, teachers, coaches, school administrators, community-based organizations and healthcare providers. We all have a role to play in this.
So, the American Lung Association has a variety of different resources for all of these different key stakeholders. I’ll call them. For lawmakers, we have our state of tobacco control report and policy positions to help protect individuals across the United States. For parents, we have free online services training courses, fact sheets and conversation guides to have fruitful, impactful messaging with your child at home. Quit services through our evidence-based Freedom From Smoking program, which is available in a variety of different methods, really to meet the needs of an individual. For coaches and school administrators, we have free online training. We have intervention programs and alternatives to suspension programs. Youth-specific cessation programs, as well as vape-free school initiatives to help with school policies. For community-based organizations, we have health equity toolkits to help address tobacco use among those marginalized communities that are still significantly impacted by tobacco use, death, disease and disparities, as well as healthcare providers resources on how systems change making that ask advisory for a standard practice of care, as well as tobacco cessation coverage, working with insurance companies, brief intervention training, specialty practice toolkits. So, for every single key stakeholder, every part of your community that you live, breathe and grow within, the American Lung Association has programs and services to help support you in working against the negative impacts of tobacco use.
Is there a misconception people have about tobacco products or smoking?
I would say one of the biggest misconceptions and the reason why the whole community needs to be on board with this is that these are individuals who are using tobacco products. They are stigmatized and they are perceived as bad people with a bad habit. This is just simply false. The truth is that these are amazing people who were unfortunately manipulated by the tobacco industry during their adolescence and tried it and unfortunately became addicted and transitioned into a lifelong dependency. Tobacco use is a chronic relapsing condition that requires repeated intervention and long-term support. If there is anything, I feel that society could increase empathy towards individuals who were manipulated as children to try these products and got unfortunately hooked and could use help in freedom from that dependency.
About Jennifer Folkenroth
Jennifer Folkenroth serves as the National Senior Director of Tobacco Programs at the American Lung Association. In this capacity, she leads initiatives aimed at reducing tobacco use and supporting cessation efforts nationwide. Her work includes overseeing the Lung Association’s Tobacco Quitline, which has experienced increased call volumes, particularly during the COVID-19 pandemic, as individuals seek assistance to quit smoking.
Please visit the American Lung Association to learn more.
