A Tailored Approach to Minority Tobacco Cessation Programs

Announcer: Welcome to #BenchToBedside, a weekly series of live conversations about recent advances in cancer, from the research bench to treatment at the patient's bedside. And now, your host and the Director of the University of Kansas Cancer Center, Dr. Roy Jensen.

Dr. Roy Jensen: Hi, I'm Dr. Roy Jensen. Thanks for joining us for today's episode of #BenchToBedside. With me is Dr. Kim Richter, a researcher with the University of Kansas Cancer Center and Director of the University of Kansas Health System's UKanQuit tobacco cessation program. About 15% of the American population smokes cigarettes, and today we're going to be talking about tobacco abuse and strategies and resources that give you the best chance to quit for good. First question, Dr. Richter, is why are cigarettes and tobacco-based products bad for our health?

Dr. Kim Richter: Well, they're really terrible for our health. They kill about 450,000 people per year directly from tobacco-related illnesses, and a lot of that is from cardiovascular disease and also cancers, and lung diseases as well. Also, we can't forget second hand smoke exposure, which kills about 40, 50,000 people a year.

Dr. Roy Jensen: As an institute designated by the National Cancer Institute, we have a unique responsibility, I believe, in reducing the burden of cancer in our region. This includes, of course, the entire State of Kansas and Western Missouri. How does tobacco cessation factor into this initiative, and what are we doing specifically to lower the tobacco utilization rate among our people?

Dr. Kim Richter: Yeah. Well, we do clinical trials on the best way to get treatment out to people, and we're especially focused on reducing health disparities, both in terms of access to really good evidence-based tobacco treatment medications and counseling, but then also in reducing disparities in terms of people being able to quit. We do a lot of research to reduce disparities, and I agree with you. As a researcher, I think that we all have responsibility to reach out and try to make a difference in our community and state. We also are accredited to provide tobacco treatment specialist training to different healthcare providers and human resource, I guess, workers or people who work with the public in general. That tobacco treatment specialist training really gives people the expertise they need to comprehensively treat tobacco. We've trained about 150 people around the state to do that. And then also, we provide really key evidence-based data on the health policies that the state is considering, like Tobacco 21 and like different kinds of coverage for cessation medications and counseling. We try to provide really good information to policymakers and providers.

Dr. Roy Jensen: Okay. As you mentioned, Tobacco 21, and its aim to reduce adolescents' exposure to tobacco products, does that include vaping and e-cigarettes?

Dr. Kim Richter: Yeah, Tobacco 21, as most places have implemented it, and also the Tobacco 21 policies that have been adopted in Kansas, and I think there are about 20, 21 communities now in Kansas that have adopted Tobacco 21, that has raised the legal sale of tobacco products to minors to the age of 21. That includes e-cigarettes and vapes.

Dr. Roy Jensen: If you're just joining us, I'm here with Dr. Kim Richter, and we're talking about tobacco cessation. And Cameron Poindexter is here in the studio to take your questions. Remember to share this link with people you think might benefit from our discussion. Use the hashtag #BenchToBedside. Earlier this year, both of us spent some time with the Kansas legislature, which is always so much fun, and in particular, the Kansas Medicaid program, which is called KanCare, expanded its tobacco cessation coverage. What are kind of the practical implications of that? What does it mean to policyholders who have Medicaid?

Dr. Kim Richter: Yeah. Well, it's a real honor, I think, and I know that you do it a lot, but for me it's a real thrill to go into the statehouse and to provide really good information to policymakers. This was about improving the treatment that people with Kansas Medicaid can get for quitting smoking. What it did, eventually, was expand the number of quit attempts that people could make per year, from one covered quit attempt, like one medication to try to quit per year and one round of counseling only for pregnant smokers, the counseling was only for pregnant smokers, per year to getting coverage for unlimited counseling and four covered quit attempts per year for the medication. I thought it was great, because with no other health condition do we say, "Oh, you've got high blood pressure. I'm going to give you this medication, and then I'll see you in a year and see how it worked." We don't really do that with any other kind of health condition, and we know that tobacco use is really hard to quit, and it's a chronic relapsing condition, so people need to try several times. This was a great way to give policymakers really good data on the importance of giving healthcare providers another tool in their armamentarium to help people quit. And it was really important, I think, for people in Medicaid, because folks in Medicaid are there because they have lower income, and we know that there are higher rates of smoking among people with low income. And they have less disposable income to go out and buy nicotine patches or anything like that. It really was a great way to kind of target resources to the people who are less able to get medications for themselves and who had higher rates of smoking, to help them quit. And also to give providers the medications and the counseling coverage they need to really deal with this in a longitudinal dynamic way to really help people quit. They can tell people now, providers can tell people, "I've got your back. If this doesn't work, we can try something else."

Dr. Roy Jensen: One of the things that both you and Ed Ellerbeck helped me understand was the fact that each individual quit attempt is an individual quit attempt on its own. Past failure is no predictor of the rate of success for that particular attempt. I think this policy, I think it's great, because it reflects research done right here at KU that showed that, and it says just because you've failed in a past attempt does not mean that we give up on you, and we're gonna say, "That was too bad. You had your chance this year." I think it's also a recognition that anything we can do to decrease smoking not only is better for the health of our population, it's also really good for the state budget as well. Medicaid expenditures, many of the things that are most avoidable are related to tobacco smoking.

Dr. Kim Richter: Absolute, yeah. And we've done some research around that as well. Dr. Tami Gurley-Calvez was commissioned by a group who was encouraging the legislators to consider this change, this expansion in tobacco treatment coverage, and she did a return on investment analysis of the cost of really comprehensively and longitudinally treating people with multiple rounds of medication and counseling, versus the savings to the healthcare system and to the State of Kansas for doing that. She found, I can't remember the exact number, but really comprehensively treating people with multiple rounds of treatment, you get quits every time, as Dr. Ellerbeck's study revealed, and you end up coming out way ahead in terms of cost. We save millions of dollars if we can really get treatment into the hands of providers, and they can get it out to patients.

Dr. Roy Jensen: Data informing public policy. What a concept.

Dr. Kim Richter: Yeah, it's a good thing.

Dr. Roy Jensen: Okay. So Dr. Richter, you are Director of the University of Kansas Health System's patient bedside tobacco cessation program, and we call that UKanQuit. Tell us kind of the unique aspects of this program and how it got started and how it works.

Dr. Kim Richter: Yeah. It started when our hospital, the University of Kansas Hospital, when we went tobacco-free in 2006, we said, "Hey, we want to keep people comfortable while they're in the hospital, maybe use it as a teachable moment." So the hospital decided to invest in a tobacco treatment service, and they partnered with our department to do that, Preventive Medicine and Public Health. It's been in existence for about 11 years. It's one of the earliest and, I think, best in the country. We actually created our model based on the Massachusetts General Hospital model for tobacco treatment, because they had a ... ... treat about 2,000 patients who are admitted to our hospital per year, and then we link them with resources when they leave. It's not confrontational. We're definitely there on their side and to make sure they're comfortable during their hospital stay as well. It's been super exciting. And then we do research within that treatment context, which is really great, because we're interacting with providers and asking them what are the issues, and then really learning what it takes to get tobacco fully integrated into hospital care.

Dr. Roy Jensen: I don't know if you know this or not, but I have a success story that I needed to tell you about, and that is from my mother-in-law, who is nearly a lifelong smoker, who came in for vascular surgery and was able to quit smoking through the UKanQuit program. How about that?

Dr. Kim Richter: Oh, that makes me so happy.

Dr. Roy Jensen: Is that good?

Dr. Kim Richter: Were you saving that? You didn't tell me about that.

Dr. Roy Jensen: I've been saving that special for you.

Dr. Kim Richter: Oh, wow. Those kind of stories just really touch me, because you know, not everybody quits when we see them in the hospital, but it really makes a difference. Many people come in time after time, so we get to know them, and we know from brief advice that that's cumulative, and it has an impact on quitting. I'm so glad for you and your family and your mother-in-law. She was able to quit. I'm glad. Yeah, that's lovely.

Dr. Roy Jensen: Good. Cameron, do we have any questions from our Facebook audience?

Cameron P.: Yes, we do have a question. We have a question from Ashley [Spalding 00:11:46]. She asks, "What are the biggest predictors, ultimate success for an individual who's had multiple quit attempts?"

Dr. Kim Richter: Well, I think number one, it's keeping trying to quit. The more quit attempts you make, the more likely you are to quit. And also, people who use medications have much higher rate or potential or odds of quitting, so using that medication is super important. I think that smokers feel sometimes like they're weak-willed, that they're not able to stop, but really they're tremendously successful people who manage very complicated lives, and medications is one way that they can help manage their quit attempt. So using medications, and also engaging in some kind of support or counseling. We can talk more about the kinds of support you can get.

Dr. Roy Jensen: Tobacco addiction and cessation are very complex issues. Could you tell us a little bit about the spectrum of research efforts that the KU Cancer Center has in this area?

Dr. Kim Richter: Absolutely. It's pretty broad. Actually, our new chair of internal medicine is doing some fabulous research on the impact of e-cigarettes on the lungs. I can't give an informed description of it, but super important research, right on the cutting edge of what's happening in the world. And then we've got folks who are doing research, like we do research on the best way to integrate tobacco treatment into sort of clinical care. And then there are other folks doing research on, for example, African Americans tend to quit at lower rates than Caucasians, and we don't really know why, so Dr. [Nicky Noland 00:13:40] has done terrific research on that. It looks like it may have to do not only with how nicotine is metabolized, but also how people smoke and the kind of products that they smoke, as well as the resources that are available to them. So all the way to health disparities. And then, as I mentioned, we were doing research on the impact of a potential policy change, so if we provided comprehensive tobacco treatment to people, and this is for people with serious mental illnesses, and provided multiple rounds of treatment in a sort of simulation, she estimated the return on investment for that for policymakers. So all the way from bench to data informing health policy.

Dr. Roy Jensen: Cameron, it looks like we have another question.

Cameron P.: Yes, we do. We do have another question. Teen vaping is becoming a huge issue. Do you have any advice on how to talk to your teen about the risks of vaping?

Dr. Kim Richter: Okay. I am happy to disclose that both of my sons vape. I mean, I'm not happy to disclose it. I could kill them, but ...

Dr. Roy Jensen: She's not gonna do that.

Dr. Kim Richter: I'm not gonna do it, but I don't want the stuff to do it either, so I totally get that. One of them has stopped since, and the other one is continuing on lighter. He wants to stop, but it's super hard. But I think the message to give them is that these things are not FDA-regulated, so we really don't know what's in the stuff, the actual e-cig device or JUUL, what materials are used in the plastics and metal. And also, the juice or the vapor, we don't know what's in that either, and it's not regulated, so it could be anything in there. Also, we know that kids who use that, a percentage of them tend to go on to use other tobacco products. I think most kids don't really want to do that nowadays. So I tell kids, don't let this new industry use you as a guinea pig, only to find out 20 years later that there are some pretty severe health risks from it. Why don't you, if you're considering it, wait until some more data are in, because right now it's kind of the Wild West out there. I like to think of e-cigarettes as, if we could have clean ones that had very, very low risks, they might be a good thing, especially for people who smoke cigarettes who are trying to quit. Probably not for kids who've never used tobacco before. But I kind of think of them right now as ... oh boy, what are they, self-driving cars? I think they're a great idea, but they are totally not ready for prime time.

Dr. Roy Jensen: Some of the research has suggested that they're actually kind of a gateway device to smoke cigarettes.

Dr. Kim Richter: And use other products.

Dr. Roy Jensen: Yeah. You know, the other, I think, important piece of information that is critical to get out there is that 31% of all cancer deaths are attributable to tobacco. That is a stunning number, when you consider that well over 600,000 individuals in this country die each and every year from cancer, and at least 200,000 of those are due to tobacco.

Dr. Kim Richter: Yeah, it's pretty incredible. If you could say, "I can give you a pill that would reduce your risk for cancer by X%," would people take it? Of course they would. But behavior change is a little harder, so when you're talking to a tobacco user about quitting smoking and how it can really reduce their risk for cancer, it's a hard sell, but it's really just like taking a pill to prevent cancer. If you quit smoking, you're reducing your risk by a lot, and if we eliminated tobacco products from the US, we'd eliminate one out of three cancers, almost. It's so important to keep at this, I think.

Dr. Roy Jensen: Right. One of the things that you have written about over the course of your career is the role that the tobacco industry plays in specifically trying to manipulate the public into becoming addicted. Some of your work has shown that what's past is prologue, in terms of the ways in which they addicted the American public to cigarettes and now how kind of the same tactics are being rolled out for e-cigarettes. Maybe you could tell us a little bit about that.

Dr. Kim Richter: Yeah. When you look at images that were advertising tobacco products 50, even 40 years ago, you can find images that are almost like the mirror image of it, but the person in the ad is holding an e-cigarette rather than a cigarette. It's pretty incredible. Dr. Roy Jensen: "Four out of five doctors favor ..." Yeah.

Dr. Kim Richter: Yes, and in the UK, their National Health System has adopted e-cigarettes as a way to quit, when there's really not good evidence for that. And so they're getting free advertising again from the medical system. I'm really glad the US has not gone that route, and it's just super frustrating. But of course, also the industry is very flexible, nimble, and now they're using social media and using other ways of getting their word out. It's really sickening and depressing, and I'm hoping that the FDA and our government gets on board with really pulling that back.

Dr. Roy Jensen: Speaking of that issue, there was an announcement yesterday that maybe you would like to comment on?

Dr. Kim Richter: Yeah. I saw it in The New York Times, but it was announced in other news outlets, that JUUL has voluntarily decided to remove some of its flavored products from the market. And JUUL, for people who aren't familiar with it, it's a nicotine delivery device that kind of looks like a flash drive, and you actually can charge it by plugging it into a computer or any kind of USB charger. It has a cartridge on it, and each cartridge has a whole pack of cigarettes' worth of nicotine in it. They come in lots of different flavors, and a lot of people who use them, especially underage kids, adolescents, they don't even know that there's nicotine in them. They've taken over, I think, 50% or more of the e-cigarette market, so they've become extremely popular extremely quickly. They have a ton of different fruit flavors, even though those have been banned from cigarettes and from tobacco products. Well, from cigarettes in particular. Those fruit flavors and other flavors are really attractive to kids. I think that the FDA is stepping up and is making signs that they're going to be regulating that or asking producers to remove those flavorings, and JUUL sort of proactively said, "Yeah, we're gonna take away some of those more popular flavors among kids, and we're also gonna ratchet back," I'm not quite sure how much, on their social media campaign, which has been very successful for them. I was really very glad to hear that. I think it's a first step. It's a good step.

Dr. Roy Jensen: Do we have any more questions, Cameron?

Cameron P.: Yeah, we had a question, but it refers back to what you just answered. They want to know if big tobacco companies are marketing to young people and teens?

Dr. Kim Richter: Big tobacco, in terms of cigarettes, well, we know ... number one, I just want to say that tobacco use and now e-cigarette use, it's a pediatric disease. It occurs in the second decade of life. In the past, it's been pretty clear that the tobacco industry has really directly tried to appeal to youth in many, many ways, because they know if they can get people addicted before the age of 18 or 21, then they're gonna have consumers who are hooked for 20, 30, 40 years. It's clear that a lot of these products are designed to be appealing to youth, I would say, and it's a shame, and it's shameful.

Dr. Roy Jensen: That brings up another point, is that initially, e-cigarettes were almost kind of a mom and pop entrepreneurial industry. What I think we've witnessed over the last decade is that basically big tobacco has seen that this is the future for them, as combustible tobacco products continue to decline, thank goodness. They're kind of muscling in and buying out smaller companies. It's clear that this is a transition process, and their future business plan is to move into this in a very aggressive way.

Dr. Kim Richter: Yeah. Yeah, it's very clear that that's happening. I think that the mom and pop places exist, but it's gonna be harder and harder for them to compete against the big companies. You know, all of this has mushroomed with a real lack of evidence, in terms of short- or long-term effects on people's health. We are an entrepreneurial society. It's what makes us great. On the other hand, we need to keep consumer health and consumer protection in the forefront of our minds, and tobacco has been a very bad actor. The e-cigarette industry definitely shouldn't be given a pass on really having to prove that its products are extremely safe, and also to prove that they are not marketing to youth, that they are not trying to catch people before the age that they are actually able to even give consent.

Dr. Roy Jensen: It's absolutely astounding to me that someone can introduce a product and have no data, not any data. Not a little bit of data, I mean no data, in terms of the long-term safety of this product and what health impacts it will have. And you mentioned earlier, our new Chair of Internal Medicine, Dr. Matthias Salathe, is really doing some pioneering research around the impact of these e-cigarette devices. This is not my area of expertise either, but basically, the presentation that you and I heard the other day was that potentially many of the chronic obstructive pulmonary issues that you see with cigarette smoking could be caused by e-cigarettes. So even if it's not packed full of the traditional carcinogens that we think about in tobacco smoke, it can still do a great deal of damage. One of the things that I think many kind of traditional combustible tobacco users don't understand is that, while maybe one out of 10 will get lung cancer, 10 out of 10 pretty much wind up getting COPD. COPD is a very serious disease that causes significant morbidity, obvious mortality, and it is not a fun way to live the last five to 10 years of your life, literally starved for oxygen.

Dr. Kim Richter: Right. Yeah, my dad died from COPD. He started smoking during World War II, and he quit, I think when I was around 11 or 12. I remember when he was quitting. And then he went on to live quite a while, but eventually it caught up with him, and it was really hard to see him have to limit his activities, and his brain was super sharp, and he was so very active, but he could barely move. And it was from his lungs. It is really interesting. People want to evaluate the safety of the e-cigarettes according to the harms of cigarettes, but e-cigarettes are very different. It took us 20 years, or 40 years maybe, to even get an inkling of the harm that was caused by regular cigarettes, and it may take us that long to see what ... although, thank goodness to Dr. Salathe's work and others, we're getting an idea of what kind of harms, new and improved harms, I don't know, that are unique to e-cigarettes. And it takes a while for that to come out, but we just need that data. And the products are still changing all the time, so it's so hard. You'll study one, and then someone will bring a new product out on the market, and you really don't know what the harms are from that. So we're playing catch-up a little bit, but the data's coming in, and I hope the funding will improve for those more basic studies, because it's just super important. We don't want to wake up 30 years from now, 40 years from now, and our kids' generation be suffering from all these new ...

Dr. Roy Jensen: Looks like we have another question, Cameron?

Cameron P.: Yes, we do. Is vaping now integrated into all cessation services you offer?

Dr. Kim Richter: Yeah. That's a great question. We have had a few people either who are dual tobacco users and vapers, or they're exclusive vapers, who have asked for our services in the hospital, and we really treat it the same way. I think the issues are very, very similar, and so yes, we do. We're not quite sure about the effects of using quit smoking medications on people who are vaping and helping them quit. Anecdotal evidence is building, and hopefully we'll have some trials on that, but there's no reason that it shouldn't work as well.

Dr. Roy Jensen: You know, one other fact that I think a lot of people don't understand is nicotine is one of the most powerful addictive drugs known to man. It ranks right up there with crack cocaine, methamphetamine, and any other kind of drug of abuse that you want to name. The idea that e-cigarettes, they're safe, we can be addicted to nicotine, and everything will be absolutely fine and hunky dory, and we'll have no consequences, it is pretty silly. I mean, let's recall all the civilizations that promoted addiction in their population, and how did that turn out for them? I can't think of one where it turned out even halfway good. It's a terrible idea. You are gonna be suffering health consequences the likes of which you have pretty much no data on. You're experimenting on yourself.

Dr. Kim Richter: Exactly.

Dr. Roy Jensen: And there's no real reason to do it.

Dr. Kim Richter: No.

Dr. Roy Jensen: As we approach the end of today's session, Dr. Richter, what resources are available from any source, and particularly in the KU Cancer Center, for someone who wants to quit tobacco or other forms of nicotine?

Dr. Kim Richter: Yeah. I think number one, it's really important for people to realize that if they have any kind of health coverage, the odds are, they're gonna have pretty decent coverage for quit-tobacco medications. The Affordable Care Act, when it was passed, required that health insurance cover any kind of preventive health services that had a grade of A or B, in terms of effectiveness. And all of the tobacco cessation medications, and also counseling, is grade A ways to quit. So you should be aware that if you have health insurance, you probably have coverage for quit-smoking medications and counseling. That's private, Medicaid, Medicare, and the VA, of course, has great quit-smoking medications and counseling coverage. Also, there's a lot of supports that are available to the public. You can call 1-800-Quit Now to get the Quit Line. If you have any kind of mental illness that gets in the way of your being able to quit, they'll ask you a few questions about that, and you can get a free two-week starter pack. That's new. That's been introduced into Kansas. That's a permanent program. It's very exciting. You could sample those things, and it can give you a little bit of breathing room until you either get your insurance to cover it or figure out a way to get the medications. One more word on the medications. Federally-qualified health clinics are really good at connecting people with pharmacy assistance programs. If you don't have any kind of health coverage, then you can get medications that way as well. You just find your local FQHC or Safety Net clinic. And then, I mentioned the Quit Line for behavioral support, because you need mediations, and you need behavioral support. Medications, most people should be pretty darned good. Behavioral support, there's the Quit Line, and then there's text messaging, which there are some studies out that show that that helps people quit, smoking in particular. And all you do is type in the word "QUIT" to 47848, and then you can get enrolled in a text messaging program to help you quit. If you go to smokefree.gov, then that's actually a website that has a number of different kinds of text messaging programs for people who use smokeless tobacco, for pregnant moms, for teens, and for vets as well. So there's tailored text messaging programs. Those are really great options. And there are some really good websites. Become an EX is a very reputable evidence-based website for quitting smoking, where you can get just really great information that's really based on the evidence.

Dr. Roy Jensen: One of the things that we're awfully proud of here at the KU Cancer Center is the fact that we recognize that tobacco cessation programs are not one-size-fits-all entities. We've actually worked with a number of underserved and minority and ethnic communities, trying to develop culturally sensitive and tailored programs that really meet the needs of specific populations. Quite a few groups in the Cancer Center have really worked with, they've worked with African Americans, they've worked with Hispanics, they've worked with-

Dr. Kim Richter: American Indians.

Dr. Roy Jensen: ... rural individuals, Native Americans.

Dr. Kim Richter: Mm-hmm (affirmative). Rural folks, yeah.

Dr. Roy Jensen: And all of these represent sort of slightly different dynamics that you have to tailor your approach to, and we recognize that, and I'm awfully proud of the fact that we are seen as a leader. And certainly your work is at the forefront of that. So congratulations. Do we have any other questions, Cameron?

Cameron P.: We do not, but we encourage you to continue the conversation by submitting your questions and comments in the comments section below the video.

Dr. Roy Jensen: All right. Well, thank you, Dr. Richter.

Dr. Kim Richter: Well, thank you.

Dr. Roy Jensen: That's it for today. If you're trying to quit tobacco, and this is the single most important decision that you can make in your life today, we strongly encourage you to utilize the resources that Dr. Richter spoke of, which are listed here. We appreciate you joining us, and we invite you to tune in next week, Wednesday at 10 a.m., for #BenchToBedside. Thanks for watching.