Discover the continuing threat of tobacco use in America in this episode of What the Health. John Salak delves into the hidden crisis of smoking with Jennifer Folkenroth, Senior Director of Nationwide Tobacco Programs for the American Lung Association. Despite significant declines in cigarette smoking since 1965, tens of millions of Americans still smoke, leading to hundreds of thousands of deaths annually. 

Learn about the ongoing battle against tobacco, new emerging threats like vaping and effective strategies for quitting. Jennifer shares valuable insights into how smoking impacts various populations, why it's so challenging to quit and what systemic changes are needed to combat this pervasive issue.

00:00 The Golden Age of Smoking

01:00 The Decline of Smoking in America

01:32 The Hidden Crisis of Tobacco Use

02:04 Interview with Jennifer Folkenroth

02:45 Progress and Challenges in Reducing Smoking

05:25 Disparities in Tobacco Use

09:38 The Addiction and Its Impact

12:25 The Rise of Alternative Tobacco Products

20:28 Efforts to Help Smokers Quit

35:41 Community and Policy Efforts

40:59 Conclusion and Final Thoughts

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Learn More about Jennifer Folkenroth:

• LinkedIn: https://www.linkedin.com/in/jennifer-h-2a985414/

And there were countless other heroes, from ballplayers to singers, who publicly puffed away as if smoking were second nature. Times, of course, have changed. Smoking is no longer cool, especially among the young. In fact, smoking is banned in so many public places, from airlines to bars to ballpark, that it seems as if Cigarettes have vanished from the American landscape.

Unfortunately, that's simply not true. Tens of millions of Americans still smoke. And hundreds of thousands die annually from the practice, either through personal puffing or second hand smoke. All this means is that smoking and tobacco use is an American hidden crisis, one that so many thought was on an irreversible decline that it was destined for total elimination.

Now, in fact, there are more ways than ever to get a nicotine tobacco hit, all of which threatens to take another generation up in flames. Our next guest is here to clear the air on the ongoing tobacco crisis, the new threats involved, and how it can be beaten. Listen up.

So welcome to what we always consider the best part of our podcast, which is when we get to delve into important subjects with very knowledgeable people. And today's subject is incredibly important tobacco use, smoking, the impact. And we have the honor and privilege of speaking with Jennifer Falkenroth, who is senior director of nationwide tobacco programs for the American Lung Association.

So Jennifer, welcome to our podcast.

[00:02:34] John Salak: so obviously we're talking about tobacco and smoking, obviously central to your work at the Lung Association but let's start with some good news, or at least what we would see as good news. Smoking, at least from what we have seen from our statistics or the statistics we've pulled, is down to its lowest level, nationwide since 1965.

Is that accurate, and why has this happened?

Smoking increased access to cessation programs that are really helping individuals to quit 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 on tobacco product prices, which has helped with encouraging individuals to quit implementing, smoke free air policies at state and federal levels. Eliminating flavored tobacco products has certainly made an impact 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 that need it.

that want to quit, as well as development and launch of American Lung Association State of Tobacco Control Report, which really 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.

It would be like walking into a London fog, and, and people were just, okay with that. That was, that was quite normal. And yet now we see this tremendous decline. Do you see this, reversal as inevitable?

Rural areas, military veterans, L. G. B. T. Q. I. Plus individuals, adults who do not graduate from high school, low income earners, uninsured persons, communities of color person suffering from a mental health and substance use disorder as well as adults living in public housing. So we are seeing these populations.

still making smoking very relevant topic, public health crisis truly to continue to shine a spotlight on and work to, find equality. There are still way too many people that continue to suffer from the devastating effects of tobacco use. And this is certainly a public health crisis we need to keep very relevant.

[00:07:03] Jennifer Folkenroth: Yes, so one of the largest reasons is they are targeted by the tobacco industry in their marketing tactics, so they know that communities of color are particularly vulnerable to addiction. The physiological pathways within the body are more susceptible to the addiction itself, so they really play off of this through tobacco industry marketing, through tobacco retail placement. 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 are seeing in, let's say, say, a predominantly, caucasian community. So they are blatantly being targeted. In addition to the tobacco industry, we are seeing these disparities. Exactly what you said, john. The, socio cultural. Circumstances of these individuals, a high stress that is occurring with LGBT plus communities, the lack of culturally competent health care being provided to communities of color or individuals with lower income. There are certainly disparities that exist here that are not setting these individuals up for success in living tobacco free lives.

We don't have to worry about it. It's just going to take care of itself. You're saying that's really not the case.

And that simply just is not the case.

And smoking and offering them virtually to everybody around from Lauren Bacall to Sydney Greenfield. It didn't matter. And it's just, you, you no longer see that, but yet you still see this prevalence of in certain groups.

[00:10:57] John Salak: I want to get into that in a second, but I also wanted to ask. Is, I don't want to say, is smoking more dangerous, but is it taking a higher impact on, on people who do smoke, obviously, and, or even from secondhand smoke, because in many ways, we're not as healthy as we were 20, 30, 40 years ago. I mean, you think of rates of obesity, lack of exercise, all of these factors allow, we've podcasts and stories, allow diseases to take a greater hold that they wouldn't have earlier.

because we're just not as healthy. Is this something we're seeing with tobacco use, whether it's smoking or other types as well?

cancers. However, 1 thing I always like to keep in mind is, tobacco is a unique legal consumer product. It is the only 1 that kills half of its users when consumed as directed. Right. 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 lot of chew and then in the car like today. Vaping we are seeing so much dual use and poly use today that we didn't see in past decades. So, even though those individuals who smoke are not as prevalent, those who are tend to use multiple products.

So we're even further compounding the unhealthy impact.

Taking place.

[00:13:35] Jennifer Folkenroth: Yeah. So variety of different tobacco products ones that folks are more aware of, cigarettes. 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's so many there's 6 different types of these e cigarette and vaping devices and over 460 brands. out on the market. So really kind of doing the math times the amount of flavors, right? This includes tanks, mods, rechargeable, disposable, 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 snooze. Now, this is a smokeless spitless packet that goes in, but derived directly from the tobacco leaf and still has some tobacco in it. So, the difference between a snooze 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 really be able to use these products undetected

[00:15:26] Jennifer Folkenroth: the majority of these products do, in fact, contain nicotine and research studies have even shown that even those that say 0 milligrams of nicotine are in fact, 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 are also having other harmful chemicals detected including propylene glycol and vegetable glycerin acrolein these are all chemicals that we know can cause irreversible lung damage.

[00:16:27] Jennifer Folkenroth: it is 1 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, for all individuals around you. So it's incredibly problematic and a huge misconception. It's not just water vapor. Like folks think it's full of chemicals.

[00:17:07] Jennifer Folkenroth: Yes, we have gone through the flavor restrictions that have taken place. However, unfortunately, there was a loophole included in this, where 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, so we also know that the FDA, although they are working very hard to get through the applications to truly understand the. Harmful impacts the risk versus benefits. If there are any, 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 not authorized by the FDA to be marketed and sold here in the United States.

[00:18:14] Jennifer Folkenroth: Yes and that's a great point to John is, athletic ability is certainly decreased through use of these products. So the fact of the matter is, when we think of smoking cigarettes, we think of our lungs, we think of lung health and here I am. From the American Lung Association,

right?

Smoking affects everywhere your blood flows throughout your body that nicotine and over 7, 000 chemicals and toxic compounds that are in cigarette smoke flow through the bloodstream throughout the entire body. This really makes the connection that cigarette smoking can directly lead to increase risks of 12 different types of cancer, cardiovascular disease. coronary heart disease, stroke, and heart attacks, 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 pre term deliveries. Still births, low birth weight, in addition now, that's just primary smoking right from the individual who is smoking, but then there is a whole list of health consequences outside of that due to secondhand smoke and the 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. Heart disease, lung cancer, stroke, asthma attacks, bronchitis, pneumonia. Sins 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 really start to see an increase in oral and esophageal cancer, periodontal disease. Tooth loss dental caries and staining of teeth. So, it really kind of 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.

[00:20:37] Jennifer Folkenroth: There's always so much more that needs to be done.

Right. 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. Your 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 go 3 hours, cold turkey and get 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. We see, unfortunately, of those 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. So that would include our FDA approved cessation medication plus counseling. So behavioral counseling, whether that be by the phone, one on one, in a group setting. We know that these two combos, that medication plus counseling, increases 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 the benefit to 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's still a lot to be made. But at the end of the day, if there's 1 thing, John, that I really wish we. Could make more significant progress on and 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 into 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. for any other chronic relapsing condition. And unfortunately we're just not there in our health systems today.

[00:23:36] Jennifer Folkenroth: There's a variety of different reasons we've heard from clinicians on why this doesn't seem to be a priority. First and foremost, some EMRs do not have this as an automatic opt out option where, treatment is a standard practice of all EMRs. The record system, right?

Another is lack and confidence in having a conversation with their patients or feeling that there are higher priority,

Health aspects that need to be addressed. There's a variety of different, challenges that we hear, but really the confidence in the referral as well as making this a priority among all of the different health complications and conditions that they are addressing with their patients each and every day. So we really work to increase that confidence, increase the resources and tools. For physicians and clinicians to be able to refer their patients into services, but also work really hard on health systems, change integration efforts in hopes that we can have cessation treatment, a standard of care, just as we would any other chronic relapsing condition.

[00:24:57] Jennifer Folkenroth: What surprises me is, how highly important they put quitting smoking and how low they put their confidence and ability to do so. 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, really hide and protect this dependency and or addiction. And how many folks want to quit alone without anyone knowing. John, I'm happy to share with you that the reason I do what I do and I am a tobacco treatment specialist as I am an ex smoker myself.

So, I was a smoker for nine and a half years and was diagnosed with cervical cancer.

In my early twenties, they said, you have to quit in order to get the surgery. I was an angry quitter, An angry quitter and I think 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 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 relapse right back into smoking. For me, telling folks, 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 difference. 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 is, it may happen and that's okay. So biggest thing I would say, folks wanting to quit alone and not tell anyone.

There are programs to assist where we know that if it's drug counseling or, or other counseling, that that's part of the recuperation or treatment process. Is it just that people aren't aware that this is how you go about quitting smoking? Or are you supposed to do what your uncle Stevie did and just stop after the second world war and eat candy to try and quell the urge.

When in fact, the majority of society doesn't understand what it feels like to be hooked onto nicotine. And what it like to try to stop doing something that you've done. 1. 5 million times over the last 20 years. So, I see tons of light bulbs go off among my clients. When I explained to them the three link chain of addiction that occurs in smokers, and I'll give it to you really simple and

straightforward. There's the mental challenges. It's the one that tells you it's. 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, right?

[00:28:47] Jennifer Folkenroth: in itself comes along 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 the mental challenges of quitting, then there's the physical, which we all think of first and foremost, right? That is taking a puff off of a cigarette. Nicotine stimulating the alpha four beta two receptors in the brain, releasing that happy, feel good chemical dopamine.

That in itself is just the physical effect. The third one really is that sociocultural or the 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.

So, in fact, folks think that quitting 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. So for those individuals, they say, okay, the physical effect. Okay. So I smack a patch on my arm or, pop of nicotine gum. You're really 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.

You can't smoke in restaurants. You can't smoke at bar. You can't smoke at baseball games. And quite honestly, I do miss the smell of cigar smoke at a baseball game. I know it's not healthy for you, but that was what I grew up with. So what it seems is that smokers are more and more likely to congregate with other smokers because that's the only place they can do it.

Well, unless they're doing it by themselves, that seems like a reinforcing structure that you're going to go find your friends who smoke. You're not going to hang out with your friends who don't smoke because they don't want you smoking around them. it's sort of a self fulfilling prophecy.

Among individuals who don't. Smokers also find friends fast,

right, particularly over the winter months when we all go outside and seek a warm huddle spot.

right.

So you're right. There's so much stigma associated and so much isolation. And yet, smokers, certainly do seek out other smokers and make fast

friends just to feel a part of the group.

[00:31:44] Jennifer Folkenroth: That's a great question. It really comes down to how the product is used. So, if you were to ask me of every single tobacco product on there, which is the most harmful in the health. 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, right? So you can take a cigarette and put it in a beaker of water and see there may be 2, 000 chemicals, but when you light those chemicals on fire, you're actually creating over 7, 000. So that carcinogenic effect certainly make increases those health impacts when it comes to e cigarettes in particular, they've really only been in utilization here in the United States for just over a decade. So, 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. Seeing, what the impact of these products are having on the health. And I will say that for e cigarettes in particular, we are seeing lung damage.

We are seeing higher susceptibility to respiratory illnesses and diseases. We are seeing, skewing of brain development along adolescence, 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 to down to how those products are used and were intended to be used by the manufacturer. However, every single 1 comes with some level of risk.

[00:33:30] Jennifer Folkenroth: I don't perceive there being a resurgence in cigarette smoking in particular. One thing I am certainly keeping my finger on the pulse of is utilization of these newer tobacco products. One thing that we know is the tobacco industry was incredibly effective in their marketing tactics for cigarettes over so many decades, right? They are using those same exact pages out of that playbook to now promote e cigarettes and vaping devices, as well as these new nicotine pouches. The nicotine pouches in particular, we are seeing an increase in utilization, mostly among adolescents. So we are seeing very effective. So if there was going to be a surge in use. I wouldn't particularly see it being across cigarettes in particular, but actually these newer tobacco products that are available on the market.

[00:34:44] Jennifer Folkenroth: So old school tobacco companies are all involved and they all do have their own line of brands. However, we are seeing some new companies popping out of the woodworks, producing these products that don't come from, the big tobacco industries that we are used to, the Philip Morris. The, you know, Lorelei, like for us we are seeing some kind of like mom and pops even come out of the woodworks in manufacturing of these new products. We still, though, are seeing the big companies as the main producers, the main marketers and the main

distributors of all e cigarettes vaping devices, nicotine pouches and many of them really kind of transitioning their internal efforts towards marketing of those because they are seeing. Such a large revenue boost in purchasing of those products above and beyond what they're even seeing with smokeless tobacco and or cigarettes.

[00:35:59] Jennifer Folkenroth: Yes. 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, schools, administrators, community based organizations, health care providers.

We all have a role to play in this. So American Lung Association has a variety of different resources for you. 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 really help protect individuals across the United States for parents.

We have free online services, training courses, fact sheets, conversation guides to really 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 trainings. We have intervention programs, alternative to suspension programs, youth specific cessation programs, as well as vape free schools initiatives to really help with school policies. For community based organizations, we have health equity toolkits to really help address tobacco use among those marginalized communities, those communities that are still. Significantly impacted by tobacco use death, disease and disparities as well as healthcare providers, resources on health 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, American Lung Association has programs and services to help support you in working, against the negative impacts of tobacco use.

[00:38:22] Jennifer Folkenroth: Yes. And if you prefer not to be online and you want to give a call 1 800 Lung USA, our Lung Health Navigators are on standby to assist you in any of your lung health needs.

[00:38:47] Jennifer Folkenroth: I would say one of the biggest misconceptions And the reason why the whole community needs on to be on board with this is, 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 really amazing people that 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. So, if there is anything, I feel that society could really increase empathy. Towards individuals who

were manipulated as children to try these products and we're got unfortunately hooked and could really use help in, freedom from that dependency.

So thank you very much for your, for your time and insights.

[00:40:27] John Salak: Before we dish out some health hacks, we want to again remind everyone of the hundreds of exclusive discounts members of our WellWellBeing community enjoy. Now, these include everything from fitness and athletic equipment to personal care products, organic foods and beverages, and more. Joining our WellWellBeing community is easy and free.

Just visit us at WellWellUSA. com, go to Milton's Discounts on the pull down menu, and you'll see the sign up sheet. Signing up takes just seconds, but the benefits can last for years. So, now it should be apparent that smoking has not been snuffed out and that new tobacco threats are flooding the market, setting the stage for a potential resurgence of tobacco use with all its devastating health consequences.

It should also be obvious that kicking the habit isn't easy. www. wellwellusa.

com The notion that someone can simply stop cold turkey is unrealistic for most. The good news, however, is that there are more ways than ever to break the nicotine tobacco habit and addiction cycle. But it is important to remember the following. Don't go it alone. Ask for help and take it from friends, family, and professionals.

Two, prescribed drug treatments and counseling are a combined and powerful solution that can help people quit. Three, if your primary care physician doesn't suggest a plan of action to kick the tobacco habit, ask specifically for help. Organizations like the American Lung Association are also powerful sources of information in the fight against tobacco use.

Finally, remember, quitting is tough, and it isn't a sign of weakness if you need help to break the habit. Relying on assistance is the smart play. Think of it as the cool play. Well, that's it for this episode of What the Health. We'd like to thank Jennifer, and Falkenroth of the American Lung Association for taking the time to speak with us on the continuing threat that tobacco presents to America.

We'd also like to strongly recommend that if you're looking for information on tobacco use and how to stop smoking or using these products, then you should visit the American Lung Association. The group can be found at Lung. org. That's Lung. org. Finally, thanks again for listening in. We hope you'll join us again soon on What the Health.