According to the Centers for Disease Control and Prevention, lung cancer is the leading cancer killer in both men and women in the United States. The main cause of lung cancer is smoking. It contributes to up to 90 percent of all lung cancer deaths.

Andrea Villanti, PhD, MPH, talks to us about lung cancer and smoking – and much more. Villanti is an associate professor in the Departments of Psychiatry and Psychology at the University of Vermont. She specializes in understanding tobacco use, including predictors and patterns of tobacco use in young people, as well as how to improve tobacco control policy and program decision making, including tobacco regulatory science.

Listen to the interview at the link below or read the transcript that follows.

What is the relationship between smoking and lung cancer?

Villanti: Cigarettes have approximately 600 ingredients, and when they’re burned, they create more than 7,000 chemicals. At least 69 of these chemicals are known to cause cancer and many of them are poisonous.

So, when a smoker inhales the smoke into their lungs, they are putting these chemicals in direct contact with their lung cells, and the cells are damaged by those chemicals. The chemicals also enter your bloodstream, which is why they cause disease in other parts of your body.

We see this with secondhand smoke exposure as well. That’s why some people who have never smoked develop lung cancer as a result of being exposed to someone in their home or in their environment who does smoke.

What percentage of tobacco users develop lung cancer?

Villanti: In the US, cigarette smoking is responsible for more than 480,000 deaths each year. That’s more than 1,300 deaths a day.

In Vermont, tobacco is one of the three behaviors that contribute to the four diseases that cause more than 50 percent of all the deaths in our state. In Vermont, we expect about 390 deaths in 2018 as a result of lung cancer.

When we think about cancer more generally, cigarette smoking accounts for nearly 20 percent of new cancer cases in the US and 30 percent of cancer deaths. That’s 1 in 5 new cancer cases and almost 1 in 3 cancer deaths.

How does lung cancer compare to other health issues in Vermont and in the US?

Villanti: Recently, I’ve heard that opioids are the major public health epidemic of our time in the way that tobacco was the public health epidemic of 20 years ago.

The problem is that the tobacco epidemic endures. Its impact on deaths in our state still far exceeds the number of opioid-related fatalities. If we look at cancer deaths alone, smoking was responsible for more than four times the number of deaths compared to opioids in 2016. If we think about other impacts of smoking, like the effect of smoking on heart disease-related deaths, that number jumps to eight times the number of deaths compared to opioid-related fatalities.

We can’t forget about tobacco, but we also cannot continue to view these epidemics of tobacco and opioid and substance use independently. Tobacco use is highly correlated with alcohol and drug use, and both have substantial impacts on the health of Vermonters and in the US more broadly.

How can we end tobacco use in our communities?

Villanti: There are two ways that we can reduce tobacco use in the community. First is to prevent people from starting to use in the first place, and second is to help tobacco users quit.

The work I do focuses on youth and young adults because we can have the largest impact on the health of the population if we do both of those things in young people. Smokers die about 10 years earlier than nonsmokers, so if we can get young people to quit before they turn 35, their experience and their survival looks much the same as a never-smoker. They get those 10 years of life back.

Better yet, if we can prevent young people from using tobacco, we can avert the long-term health consequences and the medical costs related to smoking. In Vermont, the lifetime healthcare costs for a smoker are over $200,000. In fact, we have the 11th highest healthcare costs per smoker in the country, so we need prevention to be a key part of our strategy to reduce those health-related costs and also to improve people’s health and life expectancy.

We have strong evidence on which to base our interventions and policies, and we know that a comprehensive approach is the most effective in reducing smoking. That includes a number of things, like instituting smoke-free and tobacco-free policies, which we’ve done a nice job of here in Vermont where we require smoke-free bars, restaurants, work sites, and hospitals, where we prohibit tobacco and e-cigarette use on public school grounds and at school-sponsored functions, in licensed childcare facilities.

We prohibit smoking in motor vehicles that are occupied by children to reduce exposure to secondhand smoke. We’re doing well there.

We can also increase the unit price of tobacco products, for example, the cost of a pack of cigarettes, and typically we do that through taxes. Studies show time and time again that increasing the price of tobacco products addresses both smoking prevention and helps people to quit. Higher prices on cigarettes convince some people to quit entirely, stop others from becoming regular smokers, and discouraged former smokers from starting again.

When we restrict tobacco use in public places and we increase the cost, we also need to provide an off-ramp for tobacco users, and that happens by supporting cessation policies and services. The Vermont Department of Health runs, which provides free counseling online, in person, and by phone, as well as providing free nicotine replacement therapy like gum, patches, and lozenges for adult tobacco users. Vermont also expanded Medicaid benefits to support tobacco cessation counseling. The reason that adult cessation is important for youth prevention as well is that when you get parents to quit smoking, especially when their kids are young, you reduce the likelihood that their kids will smoke.

What are some new approaches to tobacco prevention and cessation?

Villanti: There are many. One of them is relevant to our state, where we have been discussing increasing the minimum age of sale of tobacco products to age 21. In Vermont currently you have to be 18 years old to buy cigarettes, cigars, e-cigarettes, hookah, smokeless tobacco, like dip and snuff, but we’re starting to lag behind our neighbors and other parts of the country in that area. There are now over 360 cities and counties and 22 states that have raised the minimum age of sale of tobacco products to 21. It’s been proposed here and we haven’t enacted it yet.

One of the main challenges we see to this policy is that there’s an argument that young adults attain a number of legal rights at age 18. They can vote, they can join the military. They should be able to make a choice, an adult choice, to use tobacco products. And there are two pieces of evidence against this argument that I find most compelling. First, we’re seeing changes in trends in tobacco use in the US, such that initiation is now moving later, and we’re seeing more young adults starting where we would previously only see adolescents starting smoking. We’re now seeing that age of smoking initiation creep up.

Second, the adolescent brain does not reach maturation until about age 25. And importantly, the part of the brain that controls decision making and self-regulation is one of the last parts to develop. So when I talk to dependent young adult smokers, they say they wish they had never started. They say they didn’t know what they were getting into when they started. The idea that smoking is a personal choice is just not true for young people, especially when we’re talking about an addictive substance like nicotine.

How do e-cigarettes fit into the picture?

Villanti: The term “e-cigarettes” encompasses a wide variety of products like vapes or mods or vape pens or JUUL. Some look like cigarettes, some look like machines, and some look like USB drives. The common factor is that they heat a nicotine solution to the point where it turns into an aerosol and can be inhaled, but the devices differ in the efficiency with which they deliver nicotine and they differ with respect to nicotine concentration and flavors in the liquids.

The way that nicotine is delivered, the likely exposure to nicotine and other chemicals differs by all of these factors, and it’s difficult to be able to assess the impact of an e-cigarette unless you’re talking about a specific device.

Now, that’s in contrast to cigarettes, which have been so highly engineered to produce a consistent experience for smokers that the nicotine level, the taste, the length of time it takes you to smoke a cigarette is about the same, and we can get a better estimate of exposure to that product and how it impacts health.

At the population level and at the individual level, there are potential benefits and potential harms of using e-cigarettes. If adult smokers were to switch completely to e-cigarettes, the current evidence suggests that there would be significant reductions in tobacco-related death and disease. However, the possibility that e-cigarettes are appealing to youth and addicting a new generation of nicotine users is a risk, especially if that nicotine use transitions from e-cigarette use to cigarette use, or other combustible product use.

People still use tobacco products. What does this say about their power?

Villanti: Nicotine is a powerfully addictive drug, and smoking in particular is tied to coping with daily stresses for a number of people.

When I talk to young adult smokers, I hear about how many have quit using other substances. They’ve quit alcohol, marijuana, they’ve quit heroin, but they don’t know how they would deal if they quit smoking. Cigarettes fill so many roles for people. They provide a break from work, from stress. They help to dictate structure in someone’s day and routine. They serve a function in easing social situations and addressing anxiety, but it’s not just the product that’s the problem.

Cigarette companies have done a brilliant job of marketing an image of smoking that’s attractive and appealing, that highlights how smoking represents confidence or coolness or rebellion or youthfulness, whatever works to sell the product. And let me be clear that the stated goal of these companies is to create lifelong consumers. They attract young people to their products because it will garner them the greatest profits.

They also have tremendous political power. In the 1990s, the major cigarette companies were charged with racketeering for covering up the fact that nicotine was addictive, that their products killed people, and that they had known this for a long time. There is no other product that when used as intended kills half of its users. If this were meat or lettuce that was making people sick, it would be pulled immediately from the shelves of a grocery store, yet we’ve known for more than 50 years that cigarettes cause lung cancer and now a range of other diseases, and they persist on the market unabated.

What can someone do if they want to quit, or know someone who wants to quit?

Villanti: I’ll tell you, when I was seven, my grandmother had a lung removed due to lung cancer, and it was only after her diagnosis that she quit smoking. She died of brain cancer when I was 10. I do this work because of her and thousands of people like her who will die from smoking – a preventable cause of death.

We’ve discussed a lot of policy options that can help people to quit smoking and to reduce tobacco use, and I want to stress that doing all of those things together is more effective than doing any one intervention alone. The most successful programs that we’ve seen have used a comprehensive strategy with all of those approaches together to drive down smoking prevalence.

One of the best things you can do for your health is not to start smoking, not to start using tobacco, and if you have started, to quit. When people ask me how to quit smoking or what they can do, I tell them that you have to throw the kitchen sink at it. It’s not just one thing. Use quit lines, counseling, medication, get support from friends and family, and above all, be willing to keep trying even if you slip. It’s hard to quit using tobacco, but every try counts.

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