Speaker 1 00:00:59 And good evening. Thank you for joining disability and progress, where we bring you insights into ideas about and discussions on disability topics. My name is Sam. I'm the host of the show. Thanks so much for tuning in Charlene dolls, my research team. Hello, Charlene it evening everyone. Thank you so much. And I hope the two doctors can hear you. Um, tonight we are speaking with Dr. April Wilhelm and Dr. Ahmed cool Carney and Dr. Wilhelm is we'll be talking to us about the university of Minnesota study on tobacco 21 policies and the use of tobacco products with adolescents. Dr. Wilhelm is a family, um, ma position, uh, with the university of Minnesota medical school and the U of M M health Fairview. Also, we'll talk about lung cancer and smoking and Dr. Kulkarni, we'll be talking about that. And Dr. Cole Connie is a medical oncologist with the university of Minnesota medical school and Masonic cancer center.
Speaker 1 00:02:05 Did I get all that guys? Yeah, I hope so. All right. Well, thank you guys very much for joining me. I really appreciate that. Um, and I think it will be obvious to who's talking since, um, um, Dr. Wilhelm is, is female. So, um, so can you start out and I, whoever feels most comfortable answering these questions, um, a spine, but, um, it's good to have you both in here. We oftentimes have a full zoom, so it's very much nice to have actually live people. So can talk a little bit about the study on the tobacco policies and what prompted the university of Minnesota to do something like this.
Speaker 2 00:02:51 Yeah. Thank you so much, Sam. I be happy to talk about that. Um, so we were interested in looking at tobacco 21 policies and the effects that they have on adolescent tobacco use for a couple of reasons. So number one, um, tobacco policies are a little bit hard to study, um, because implementation can vary. And we had a kind of a perfect setup where we had data from adolescents who, um, that predated tobacco 21 policy being implemented at the local level in a number of different places within Minnesota, and then a number of localities that didn't have these tobacco policies. And we had follow-up data three years later, once there were quite a few policies in place. So it was kind of a perfect opportunity to ask a question about how tobacco policies are affecting adolescent tobacco years.
Speaker 1 00:03:42 And I'm just curious, they call it tobacco 21 policies. Is there 21 of them or was this done in 2021?
Speaker 2 00:03:48 Uh, yeah, no, that's a great question. The reason why it's called tobacco 21 is because it raises the legal sales age of tobacco products.
Speaker 1 00:03:57 Gotcha. Thank you. Um, so I know the study looked at, you know, how the findings deferred and the age thing. And so can you talk a little bit about, especially with, I think you there, I think I read there was a difference in like eighth and ninth graders as opposed to high schoolers, um, how did the study differ with
Speaker 2 00:04:18 Yeah, so, um, this was also a really good opportunity to look at grade level differences in tobacco 21 policy effects, because really that hadn't been looked at in great detail prior to our work. Um, so we were able to separate out because we had a substantial number of eighth, ninth, and 11th graders, um, to look at grade level effects. And what we found is that for eighth and ninth graders in communities where tobacco 21 policies were present, um, those individuals were less likely to report use of several tobacco products, including cigarettes e-cigarettes and flavored tobacco compared to their peers and communities that did not have these policies. Um, so that was for eighth and ninth graders. And unfortunately we did not observe a similar relationship between, um, 11th graders who were exposed and 11th graders who were not experienced because well, that's to interpretation. Uh, we don't know for sure, but, uh, we have a couple of educated guesses.
Speaker 2 00:05:17 So one of the reasons why we think this might happen is 11th graders behave differently from eighth to ninth graders in several ways. They tend to have older peer connections and are more socially mobile because they can drive. Um, so they might have been able to skirt these locally implemented tobacco 21 policies by going to communities where these policies were not in place or being socially connected to young people who could go. Um, and they also are just exposed to older kids generally. Um, so when they're traveling in circles, it might be easier to pass for over 21. If, um, there, the, of this policy is not very strong.
Speaker 1 00:06:00 Talk about the difference between an e-cig and a cigarette. I think most people probably know, but what, is there a difference in how much tobacco each one has?
Speaker 2 00:06:10 Yeah, that's a really good question. And I think it varies to a large degree. Um, so some e-cigarettes claim to have no tobacco use in them really. Uh, no nicotine, I should say. Um, it's a little bit semantic, but nicotine is what's actually contained within, um, e-cigarettes as opposed to tobacco products, there's no true tobacco. Um, but the, the percentage of nicotine in these products is highly variable and not particularly well regulated historically, that's getting better, but some of these products have really high levels of nicotine, uh, relative to cigarettes. And adolescents can consume a really large concentration of nicotine in a short period of time, without necessarily being aware of how much they're using. And of course,
Speaker 1 00:06:56 Nicotine is the thing that they're getting addicted
Speaker 2 00:06:59 To. Yeah. So nicotine is the habit forming component of tobacco products. So this is really concerning. Is there a different
Speaker 1 00:07:07 Between the flavored or is, are some of the flavored ones, right? Yeah.
Speaker 2 00:07:14 Yeah. So, uh, tobacco products can be flavored across the whole host of products, right? You have flavored cigarettes, um, menthol cigarettes in particular, pretty common in certain populations, but, um, e-cigarettes being flavored has been one of the mechanisms by which they've increased the appeal to young people, um, because the flavors sometimes lead people to believe that they're less dangerous and, and tend to, to really build a pattern of use in young people.
Speaker 1 00:07:42 So since the policy or the law has been raised to 21 for people to buy tobacco products, do you feel that this has helped, you know, kind of youngsters or younger people not
Speaker 2 00:07:59 Dart? Yeah. So that's actually the whole point of the policy is to try to discourage use among young people, because we know that over 95% of, um, adults actually started smoking when they were under the age of 21. So if we can reduce the level of young people who start smoking in their adolescent period were less likely to have adult smokers longterm. So we hope the policies work. We've seen some early evidence in this study and several others that have come out over the last couple of years that these policies do appear to work. Um, but there, you know, there are some variations in our ability to study that and it really comes down to enforcement, which is going to be a much more challenging, um, not to crack, I think.
Speaker 1 00:08:45 Right. Um, yes. And I, I think you studied eighth and ninth graders. I think God, I was 13 when I was in eighth grade. So incredibly young, um, you talked about real world data being so hard to get. Um, why was that so limited and are we talking real world? Are we talking all the states together that are doing something like this? Or just,
Speaker 2 00:09:13 Yeah, that's an excellent question. So I think one of the reasons why this has been such a hard thing to study is because there's such diversity in the way that these policies have been adapted across the states. Um, historically I should say, and, and that is still true at the state and local level more recently, there's been federal legislation. So in December of 2019 federal tobacco, 21 legislation was actually passed. And, um, since that time more and more states have adopted 2019, uh, sorry, um, tobacco 21 policies. So Minnesota actually adopted a bill in may of 2020. Um, but I think this, this vast number of differences in adoption of these policies has made it really tricky to study, um, because it's hard to compare, like put people in groups when the policy implementation is so variable.
Speaker 1 00:10:09 It sounds like the it's not necessarily the same across the state.
Speaker 2 00:10:15 So in Minnesota, there's local differences with still today, um, with how these tobacco policies have been, uh, passed. But now we have statewide legislation. So hopefully that will bring everything under, um, the same uniform tobacco policy enforcement.
Speaker 1 00:10:33 I see. So you were doing this study when things were pretty difficult to enforce.
Speaker 2 00:10:39 I'm hoping that this statewide and federal tobacco 21 legislation will really help with enforcement. I haven't seen any studies that have shown that, but generally with other policies when they're passed. Um, and, and there's like a higher level of precedent, um, and oversight generally, uh, enforcement increases.
Speaker 1 00:11:01 Did you feel like the use of flavored tobacco was higher in these? Did you do anything that looked at that, that maybe the flavored tobacco is higher in younger people than regular cigarettes?
Speaker 2 00:11:14 Yeah, so we, not in this study that wasn't something that we specifically looked at, but we do know that flavored tobacco use tends to be quite high in adolescents. Um, and that is both flavored tobacco in the form of e-cigarettes as well as cigarettes and, and water pipes and other forms. So, uh, we know that that's a particular, particular area of vulnerability among adolescents. And so we looked at whether tobacco 21 policy appeared to affect flavor tobacco, as well as some of those other more specific products.
Speaker 1 00:11:47 So Dr. Wilhelm, what was the highest age this went up to?
Speaker 2 00:11:52 Uh, we didn't look at age specifically. We were just looking at 11th grade, but typically
Speaker 1 00:11:57 11th graders are 15 to 16 years of age. Yeah. Yeah. So I'm wondering, um, Dr. Kulkarni, this might be for you. Um, are you seeing a lot of younger, you know, lung disease patients now from the tobacco and young tobacco use?
Speaker 3 00:12:17 Yeah, thanks for having me. Um, so, you know, it is not clear at this time if e-cigarette use, uh, increases our risk for developing lung cancer. Um, part of the reason is this is a relatively new to the market and there is much isn't much research yet on these, uh, potential long-term health effects of e-cigarettes. However, um, there is, uh, overwhelming scientific evidence that e-cigarettes still deliver some of the same chemicals, uh, linked to cancer. Um, although the amount of chemicals is significantly lower than your traditional cigarettes. Uh, you know, some of these include carcinogen carcinogens that are related to nicotine and others, um, in the liquids that are used in the e-cigarettes. However, uh, there've been several studies, um, outside of humans in, in mice, et cetera, showing that these derivatives can still cause cancer. Now, the thing to remember is that there is a lag time, um, in, in developing lung cancer, uh, following cigarette smoke exposure, perhaps up to 20 years. So, um, you know, so it's still early to, uh, you know, make that specific, um, uh, observations. But, you know, I hope that in the next few years we'll be able to tell more definitively,
Speaker 1 00:13:46 Do you know, are these policies, are they different in every state? I presume the laws are different in pertaining to cigarettes and smoking in each.
Speaker 2 00:13:56 Yeah. So that's one of the things that the federal tobacco 21 policy attempted to correct is that there was a lot of difference in state level implementation of these policies and, and exactly what the policies included. For example, some states and localities that had passed these policies actually had penalties for the young people who were purchasing these products, um, which w really is not considered to be the most effective way of implementing. Um, these tobacco 21 policies, really retailer focused efforts are preferred, um, as kind of they're the perfect tobacco 21 policy. And so, um, we are hoping that as the federal mandates get rolled out related to their tobacco 21 policies that state statewide the implementation will align more closely with the federal policies to really focus on retailers and compliance with identification checks, as opposed to putting the penalties on that, the users of the products, the purchaser themselves,
Speaker 1 00:15:00 How hard is it to enforce identification checks?
Speaker 2 00:15:04 Yeah, I am not an expert in that area. Um, but I, I, from the reading that I've done and certainly talking to my colleagues in the department of health, I think it is quite challenging, right? Because there are so many different tobacco retailers, if you think they're, I mean, there's vape shops. Um, but a lot of kids are actually buying these at the corner markets. And so it's, it's really quite challenging to enforce, um, with any degree of integrity, right? So that's actually where I think more effort needs to be focused is, um, how do we incentivize retailers to follow these policies to really restrict access to young people
Speaker 1 00:15:43 And Dr. Kulkarni, do you see, like if somebody comes into your office and they said I've been smoking since I've been 15, a difference in their lung stuff, as opposed to somebody who started smoking maybe in their twenties and thirties.
Speaker 3 00:15:56 That's a great question. And so, yeah, so, um, w from what we know, uh, the damage to the lung caused by smoking is cumulative. Meaning that the more you smoke, the more chronic exposure to smoke, uh, from smoking leads to, uh, more, uh, more impact on the health within the lungs. And therefore the downstream effects on the health are also amplified.
Speaker 1 00:16:24 Is there an average age that you tend to hear about people starting to smoke?
Speaker 2 00:16:30 Yeah. In terms of just tobacco use more broadly, it starts really young, like early adolescents and a lot of, uh, individuals. So I mean, 11, 12, some people are already using tobacco products to some extent. And we've actually seen earlier in earlier use of these, um, vaping products in adolescents, which is quite alarming.
Speaker 1 00:16:51 Is there a preference, like, do you see females are more likely than males or vice versa
Speaker 2 00:16:59 With vaping? It, it varies by population. I wouldn't say that they're striking gender different differences in the adolescent general population, but there are differences when you look at specific ethnic populations, um, to some extent.
Speaker 1 00:17:15 So these policies that kind of talk a lot about compliance checks, and it seems like it might be different or difficult to apply them. Is there, how are they planning to do that? Because like you said, there's vape shops, there's no corner, um, markets, if they decide to sell. Um, I, I know I used to support a specific place to get my, in my, my drugs if I needed them as far as prescriptions, because they stopped selling tobacco paraphernalia and I'm like, I will support anybody does that. So ha I don't, I wonder how they would, you know, apply the compliance deal. Yeah.
Speaker 2 00:18:00 I'm not 100% sure cause that's not necessarily my area, but w we might build off of some of the alcohol, uh, compliance that's been done in the past. Right. So having young people who appear younger than 21 go in to purchase products and, and kind of as a sting operation to see if, if the businesses are following, uh, their requirements or not, could be one way of building off of this. And that's, that's been a strategy used for alcohol sales.
Speaker 1 00:18:29 And you said there's communities that you see a higher usage in more than others. Are they ethnic? They are ethnically different or,
Speaker 2 00:18:39 Yeah. When you look at vaping data, um, there are differences by ethnicity. Uh, white youth are more likely to use e-cigarettes than other ethnicities, um, initially, and that actually still holds true for the most part, but there are increases across ethnic communities now. Um, so one of the areas that I've done some research and is looking at our Somali youth in Minnesota, and they've had rising levels of e-cigarette use, uh, relative to where they were a few years ago, um, which reflect the general adolescent population. And I'm also working on a study right now, looking at some of our Asian immigrant populations, um, and adolescents growing up within those communities. And we're seeing very similar patterns of growing e-cigarette use lagging behind, um, in terms of overall levels compared to general adolescent populations. But, but definitely growing.
Speaker 1 00:19:32 I'm wondering, I know, I see, you know, talks and lectures about trying to start trying to stop young people from smoking. And, and I'm totally on board with that, but I'm thinking, so when is it okay for an older person to start smoking? So what, is there anything that, you know, that people are doing to try to kind of short of, um, warnings on that cigarette package?
Speaker 2 00:19:57 Yeah, I mean, I think some of it falls into the hands of primary care doctors like myself to really be having these conversations with our patients about risks of using some of these products. And I think framing it in terms of risk reduction for smokers is one strategy for people who are already using tobacco products. But if we're thinking purely about prevention, the messaging really needs to be, don't start. These products can be to other products and can be very dangerous. Um, so it, it kind of depends on if you're talking about people who are already using other products or not.
Speaker 1 00:20:30 Yes. So Dr. Cooled Carney, I'm presuming that once people get to you, the damage is already done. Um, is that so
Speaker 3 00:20:42 Yes, correct. So, I mean, by the time patients, uh, who come to meet, see me already have most of them already have diagnosis of lung cancer or are, you know, have a suspicion of lung cancer. However, you know, things could still change if, um, if someone decides to stop smoking. And this is specifically I think, uh, to people who've had a long smoking history. Now, if you look at the statistics, um, um, smoking is estimated to account for about 80 to 90% of all lung cancer cases. However, if someone decides to stop smoking and they don't smoke for about 15 years, their risk for lung cancer decreases to very close to someone who is a non-smoker really,
Speaker 1 00:21:41 I had no idea. So I have occasionally read something that says, um, smoking is, you know, can extend to other types of cancers such as breast cancer. How true is that?
Speaker 3 00:21:56 Yeah. Yeah. That's a great question. So smoking is associated with a number of cancers in the body, not only lung cancer, um, things like cancer of the head and neck. So oral cancers, throat cancers are associated with smoking salvageable cancers, stomach cancers, pancreatic cancers are also associated with smoking. There's also association of colon cancer with smoking. So there've been a number of cancers that have, um, you know, cancer, uh, exposure to smoking as a risk factor.
Speaker 1 00:22:33 Dr. Wilhelm, how many policies were you looking at when you did the study?
Speaker 2 00:22:39 Yeah, so this study just looked at locally implemented tobacco 21 policies. And unfortunately we weren't able to look at other existing flavored tobacco or menthol tobacco policies. We just didn't have a large enough sample size to really assess for the, um, concurrent or, um, similar impacts that they could've had. So that's something that we need to look at in the future is how do you, some of these supplemental policies work together, um, to help reduce adolescent tobacco use and what
Speaker 1 00:23:09 Will they do with this study?
Speaker 2 00:23:12 Yeah, so I think this study is really encouraging because it shows that implementation of these policies can work, um, even under less than optimal situations for young people. And even though we didn't see an effect among 11th graders in this particular study, when we're looking at locally implemented policies, if these policies are then implemented at the state and federal level, as they are now, that suggests that they'll have even more of an impact and probably will help benefit this older adolescent population as well. So the findings are actually really encouraging that these policies appear to work and do their
Speaker 1 00:23:45 Job. Excellent. Um, so Dr. Kulkarni, can you give us a little bit of a lay person's, um, description of lung cancer?
Speaker 3 00:23:58 Yeah. You know, we are just all, this is a great time to talk about it because I think November was lung cancer awareness month. Uh, but you know, the spirit continues, right. Um, so, you know, so lung cancer is the second most common cancer, uh, in our country. And, but the leading cause of cancer related death now last year alone, there've been about 230,000, uh, people diagnosed with lung cancer and about half of them. So about 130% of 130,000 persons died from lung cancer and
Speaker 1 00:24:38 Other different kinds of lung cancer.
Speaker 3 00:24:41 Yeah. Yeah. So, uh, so lung cancer, if you, if you, in generally speaking, uh, lung cancer can be, can be any cancer that arise in the lungs or around the lining of the lungs. So this can be, uh, either one of the three, most types of lung cancers. These are, you know, referred to as non-small cell lung cancer, which is the most common type accounting for about 85% of, uh, of lung cancer cases.
Speaker 1 00:25:14 Non-small cell. So we're talking large cell,
Speaker 3 00:25:17 Uh, yes. So, you know, the naming by the pathologist is a little bit, you know, not
Speaker 1 00:25:24 Misnomer,
Speaker 3 00:25:25 Right? So, you know, so the way they make the diagnosis is look at the size of the cells, uh, under the microscope and, and they compare it to some other cell and what is the relative size of those cancer cell? So that is why it's called non small cell. The other type of lung cancer is a small cell lung cancer, which is of about which accounts for about 15% of our lung cancer cases, uh, which is a little more aggressive form of lung cancer than the non-small cell lung cancer.
Speaker 1 00:25:56 And these would be people who didn't smoke.
Speaker 3 00:26:00 No, in fact, um, you know, as I said before, nearly, uh, 80 to 90% of all patients with lung cancer have some exposure to smoking. However, now you bring up a great point that what are the other potential causes of lung cancer apart from smoking. Now we know that, you know, not only active smoking, but passive smoking is also, uh, you know, being one of the important risk factors for lung cancer,
Speaker 1 00:26:34 Maybe growing up in a household where your parents smoked
Speaker 3 00:26:38 That's correct. Or even, uh, living with someone who, you know, chronically
Speaker 1 00:26:45 Somebody. Yeah. Okay.
Speaker 3 00:26:47 Yep. So passive smoking is also a risk factor. There are other risk factors for lung cancer include exposure to radon gas. You might have heard, you know, if you buy a new house, they, you have to really check for radon levels in a basement. That's the reason, one of the reasons, uh, the other risk factors include air pollution, um, especially in, in countries, whereas a lot of air pollution like China and India. So there've been increasing cases of lung cancer, other, uh, causes of lung cancer. Rare ones has exposure to heavy metals like arsenic, cadmium beryllium, et cetera. Um, there are also, uh, cases of lung cancer that associated in families, meaning if there is a family history of lung cancer, sometimes, uh, there can be an increased risk for lung cancer running in those families. So there are some unknown genetic risk factors as well.
Speaker 1 00:27:48 I have a friend, um, in fact her birthday has just passed. She died of lung cancer and she was in her forties. Um, it was very distressing to me because she was not a smoker, but I do know she grew up in a family that people smoked in her family. Um, so how common is that not to grow up in a family of smokers, but to have lung issues later because you grew up in that.
Speaker 3 00:28:17 Yeah. You know, that's a great point, you know? Yeah. So as I said, passive smoking is a, you know, is a known risk factor for lung cancer. Whoever, you know, I usually tell patients that if you have a lung, you can get lung cancer. Right? So another thing to keep in mind is that there is in the society, there's a lot of stigma associated with smoking. And one of the biggest reasons for a delayed diagnosis is that patients do not want to get screening done because they are either feel embarrassed or guilty for smoking.
Speaker 1 00:28:56 So you talked about the different lung cancers, Dr. Kulkarni. I wonder if you will talk about screening, you were just getting ready to talk about this.
Speaker 3 00:29:06 Yeah, that was a nice kind of segue question. So, you know, so, uh, so lung cancer screening, um, has, uh, you know, been recommended by all the health, um, uh, entities in this country. Now, typically, uh, the recommendations for lung cancer screening were actually just updated early this year. Um, and any adult, uh, aged between 50 to 80 years who have, um, smoked at least 20 pack year smoking history. And what means is if you've smoked about a pack per day for 20 years on an average, or for instance, half a pack a day for 40 years, um, and who currently smoke or have quit within the last 15 years. So these are the high risk group of people who need to get screening with what we call a low dose CT scan annually.
Speaker 1 00:30:12 And how does this work?
Speaker 3 00:30:14 So basically you go to your primary care provider and then, um, mentioned to them that, well, I am in this high risk group because I, you know, I smoked for these many years, et cetera. And, um, the primary care provider will, um, we'll basically assess and see if the person fits in that, you know, higher risk group. And if he does, they just order, it's just a CT scan, it's a regular low, very low dose CT scan. And, um, and then you you're, you're done.
Speaker 1 00:30:47 How accurate is it?
Speaker 3 00:30:51 Um, so accuracy. Um, so that's, uh, uh, that's a great question with, for which we have to kind of dig into details for the big lung cancer screening, but in general, um, what we call the sensitivity of, uh, these tests, uh, can range anywhere from 65% to 95%. Um, and what we call the specific city of these tests. And I can help explain that a little bit better. So sensitivity is something where the probability of finding a lung cancer, um, if it is their specificity is nothing, but, um, if you, if someone has a positive test, what is the likelihood that it's true or false? So for one, for a screening test to be, uh, accurate, you need to have a very high sensitivity and very high specificity. So that would be your ideal test. Um, as I mentioned before, with, with these, uh, procedures, the lung cancer screening, the sensitivity is in the range of 65 to 95%. And the specificity is in the range of 75 to 95%.
Speaker 1 00:32:07 All right. So you discussed the, um, you know, who should get this type of screening. What about the odd person, as I talked about earlier, grows up in a family of smokers. You don't know what other else they'd been exposed to, but they in themselves didn't smoke, but they develop a cough and it just doesn't go away. How do they, you know, they get nervous, how do they convince their doctor? Maybe I should be screened, or when do you decide that? Yeah.
Speaker 3 00:32:36 Yeah, absolutely. That's uh, that's a great question. So, uh, so there are few symptoms that makes one worried about having a lung cancer, irrespective of exposure to smoke or irrespective of any history of smoking. Uh, these could be, um, um, you know, things like cough that doesn't go away for a number of months, um, shortness of breath that slowly and gradually progressive people start losing weight. So these are the, you know, what we call like alarming signs and symptoms, which might suggest that there's probably something going on that needs to be evaluated. And if that includes, you know, a CT scan of the, you know, the chest, you know, you would be able to, you know, capture most of those lung cancers.
Speaker 1 00:33:29 I want to jump back a minute and ask two questions. Either one of you, I, I, I read a little bit on, uh, something that people talked about nicotine brain. And can you give me a definition of what that is? And the second thing is besides that, oh, my parents do it. What do you find or do here is the most other common excuse for why somebody started to smoke?
Speaker 2 00:33:56 Yeah, so nicotine brain, um, is it a little bit hard to describe succinctly, but essentially there are a lot of effects that nicotine can have on the brain. Um, you know, and, and it's a product that we become habituated to and can become dependent on, which is really why it's such an addictive, one of the most addictive substances out there. Um, I am most familiar with how it affects the adolescent brain, so I can speak a little bit more to that. Uh, we have a lot of concerns about how nicotine exposure can have significant and potentially lasting, although the data are still, um, you know, in the early stages, uh, but definitely significant impacts on how the adolescent brain is able to learn, uh, pay attention to, and really concentrate on, uh, remember things correctly and also regulate things like mood, uh, after exposure to,
Speaker 1 00:34:56 I have seen that with people. Yeah. Adults though. I don't think that, I don't think that's just,
Speaker 2 00:35:03 It's not just teenagers, but that's why we were particularly worried is adolescents are still developing in terms of their brain development. You know, you're still developing that brain until well into your twenties. And so if these tobacco products that have high levels of nicotine in them are really affecting our ability to learn and remember and pay attention that can obviously affect our school performance and, um, as well as potentially judgment, right. And it can lead to, uh, adoption of other risk behaviors. Uh, so there are some concerns about how nicotine products could be gateways to other, um, high risk behaviors, um, such as other drugs, other tobacco products that is somewhat controversial in terms of the number of people that it affects in that way. Um, but definitely the, the potential risk is there.
Speaker 1 00:35:54 And what about the excuse besides family smoking? What else is like, what would be the next big excuse you hear somebody why they started?
Speaker 2 00:36:04 Yeah. So in terms of influences on decisions around tobacco use, it's really complex. Um, so family level influences like norms within the family and exposure to tobacco products is, and the home tobacco environment are really influential factors in why adolescents may decide to start using tobacco products. Uh, but then the other big influence, I think we can all remember our high school days of facing peer pressure, right? I mean, it's the cool thing to do. And if you don't fully understand the risks associated with these products, it can lead you to become quite susceptible. So I think, um, some of the marketing that has gone on around these products being safer and flavored and not containing nicotine can just lead to misperceptions about when there is real risk, uh, for starting use that can get really confusing to sort out,
Speaker 1 00:37:00 You know, as an adult, I think, um, I, I might've believed that 40, 50 years ago, but now it feels like it's in so much of the public, you know, like there it's just everywhere how dangerous it is. I can't believe that somebody would you as well. I could believe they'd use it, but I could never buy that. They'd say, I didn't know. It was so dangerous because it feels like the advertisement is also that, of how dangerous it is. So out there.
Speaker 2 00:37:30 Yeah. Well, I would draw a distinction between smoking, which most people know is quite dangerous if they've grown up in the United States and vaping or e-cigarettes right. Because I feel like there it's a relatively new set of products. Hasn't been regulated to the same degree as other nicotine containing products. And these tobacco companies have really gone after the consumer of adolescents with ads that downplay the risks, uh, quite tremendously and are purposefully targeting young people.
Speaker 1 00:38:03 Let's see sometime in our program. I usually let my research person, um, ask questions. So Charlene, I wonder, is there anything that I'm going to go on to talk about treatments, but is there anything you'd like to ask before we delve into that? Maybe she hears me.
Speaker 4 00:38:22 I I'm just overwhelmed with the information and the way you guys are explained it. It's, it's very simple and it can't understand it and there's something really wrong. Cause you guys are putting it out there in a way that people should be able to understand.
Speaker 1 00:38:40 Did you guys hear her? Yes. Okay. All right. Well, I wonder if, um, you would, we'd go in and talk about, um, treatments. Um, I know there are some things about, you know, treatments with lung cancer. I don't know if you call them treatments or what the longevity is of them when you're taking a treatment for lung cancer. But can you talk a little bit about that?
Speaker 3 00:39:06 Yeah, well, you know, that's, uh, a difficult question to answer in five minutes, but I will try my best to kind of succinctly answer. I can, I can be your whole day talking about treatments for lung cancer. Um, so basically, uh, in generally speaking, the treatment depends upon the type of lung cancer and also the stage of lung cancer. Now, typically lung cancers are staged from stage one through four, where four means that the cancer has widely spread throughout the body outside of the lung. Whereas stage one and stage two are relatively early stage lung cancers. Now with early stage lung cancers, there is a potential for cure if caught early and typically the way we treat these early stage lung cancers are surgery. So the surgical resections, they go to surgeon, he removes the part of the lung, um, which has the cancer in it. And then some patients get, uh, chemotherapy following the surgery.
Speaker 1 00:40:14 And can I, I just want to stop him and it's so cured to you means it's gone and you should be able to go about your life and live probably just as long as anybody else,
Speaker 3 00:40:25 Most of the times. Yes. So typically in someone with early stage lung cancer who get the full treatment or surgery and maybe chemotherapy, um, the chance of cure is pretty high is in the range of 60 to 70%, again, depending on what stage they are. Yeah.
Speaker 1 00:40:44 Okay. But,
Speaker 3 00:40:48 And, um, the, the more advanced the stage, the more, um, uh, the more complicated the treatments get. Um, so for stage three cancers, for instance, most of them initially start with combination of chemotherapy and radiation, um, for a few weeks. And then after that they, they might get either more chemotherapy or, you know, more systemic treatments, um, like immunotherapy.
Speaker 1 00:41:23 I heard a lot of excellent things about immunotherapy. Is there a reason why that doesn't work to totally cure
Speaker 3 00:41:32 That's? Uh, that's a great question. So yeah, so immunotherapy, just for others, so that understand what, what I'm speaking here. So immunotherapy is one of the recent advances that has changed the face of treatment for lung cancer. And it has, you know, tremendously improved survival, even with patients with stage four lung cancer. Uh, the way it acts is it's a little bit different than chemotherapy. Um, it basically activates our own immune system so that they can recognize and kill cancer cells. Now, none of the treatments work perfectly well, meaning there will be some patients who still don't respond to immunotherapy. And currently they're active research going on as to identify what might be those factors in which might either lead to what we call a primary resistance, meaning there is absolutely no response to immunotherapy or what we call an acquired resistance, where in someone who initially responds to immunotherapy, but then later stops responding and then progresses.
Speaker 1 00:42:44 Yeah. So it wouldn't immunotherapy be better than chemotherapy in general.
Speaker 3 00:42:53 That's uh, so overall, you know, immunotherapy's relatively better tolerated than chemotherapy. Um, nonetheless it does have some side effects, uh, which, which can be, um, uh, severe, um, overall I think it depends on so many factors, you know, patient related factors, um, what the cancer is, uh, if you have to decide between, uh, choosing immunotherapy alone, or sometimes we do even a combination of both chemotherapy and immunotherapy,
Speaker 1 00:43:35 Can you do lung transplants with people who've had lung cancer?
Speaker 3 00:43:41 Um, there is limited data to suggest that lung transplant work, um, because we have such effective treatments in early stage lung cancers. Um, you know, you typically don't need a transplant with, with stage four cancers, meaning that cancers that have, um, you know, spread outside of the lungs
Speaker 1 00:44:08 Task to size probably and
Speaker 3 00:44:10 Everything. Yeah. So typically lung lung transplant wouldn't work because of the cancer has already moved outside of the lung. Right.
Speaker 1 00:44:19 What I have heard of people having like emphysema and I presume that was from smoking or something similar to that. Can you give me a definition and is that like a preload to lung cancer?
Speaker 3 00:44:33 Yeah. So that's a great question. Now, I just want to finish saying, you know, that, you know, just a little more, um, you know, um, information on, on treatment, you know, for stage four cancers is typically with lung cancer. Now we typically do, um, you know, what we call genetic testing on the tumor, uh, to look at, you know, specific, um, alterations in the DNA that could be targeted with oral type of chemotherapy drugs. So that's been something that's, uh, kind of new in the last, maybe six to seven years that we've now have about 10 different drugs that can be given in someone who harbored that specific mutation.
Speaker 1 00:45:18 And is that a more precise chemotherapy?
Speaker 3 00:45:23 Yeah. You can call that, you know, we like to call it precision oncology or precision medicine where these drugs are given specifically to target those mutations.
Speaker 1 00:45:36 And then what about the emphysema?
Speaker 3 00:45:39 Yeah, so coming to emphysema, so, uh, emphysema is basically, um, a result of long-term exposure to smoking. And it is a part of a spectrum of effects from long-term smoking, which we call as CLPD or chronic obstructive pulmonary disorder. And what happens is that in people who smoke for a long time, the, the chemicals damage, uh, those, uh, air SACS, which are in the lungs and we call this alveoli and these air sacks or time as they are damage, they, um, trap air in them. And as they trap air, they begin to expand. And eventually the entire lung is kind of replaced with this dilated or, you know, expanded airways. And patients usually have symptoms like shortness of breath, um, cough, wheezing, um, you know, those kinds of things. If you, if the emphysema becomes a much more severe,
Speaker 1 00:46:51 Can any of this be reversed?
Speaker 3 00:46:53 Uh, so by the time someone develops emphysema, it's usually irreversible. So as I said, previously, you know, the damage is cumulative. So the earlier you intervene by either smoking or stopping smoking. I mean, um, the lesser, the likelihood of further damage
Speaker 1 00:47:14 You talked about, you know, if you stop smoking early enough and, um, stay stopped that that can undo some of the damage. Are there other things that help undo it as well?
Speaker 3 00:47:30 Um, I can't think of anything specific that might help, um,
Speaker 1 00:47:35 Exercise play into anything.
Speaker 3 00:47:37 Yes. So definitely, you know, we've, we've known that, you know, exercise and diet have a role to play in, you know, in, in ways that we still are trying to understand well, in, in the general health and wellbeing, but specifically for, and fight and fight SEMA, you know, exercise, if you, if you try to exercise, it can help with improving exercise tolerance over time.
Speaker 1 00:48:07 And does what is emphysema then it's like heart failure that happens, or what is the, it just gradually gets worse.
Speaker 3 00:48:18 Yeah. So, yeah, exactly. So as, as an, when, you know, as I said, previously, the damage is mostly irreversible and in someone who does not stop smoking, eventually it can lead to, you know, uh, uh, you know, things like pulmonary hypertension or heart failure, even.
Speaker 1 00:48:40 How do you explain when, you know, the person who smoked for 15 years, 20 years gets sick and the person has smoked for 30 40, and they're still going.
Speaker 3 00:48:53 Yeah. Yeah. That's a great question. And that is something that we are still trying to understand. Well, you know, uh, although smoking, um, you know, is, is, is associated in, in a majority of the patients with lung cancer, uh, there is no clear, uh, you know, uh, relationship between, um, you know, Y you know, some people despite smoking for 40 years get lung cancer while others, uh, you know, don't, um, so there are still some unknown genetic factors and probably other environmental factors that we are still trying to understand, which might predispose to lung cancer.
Speaker 1 00:49:36 Well, Dr. Wilhelm and Dr. Cool Connie, I really appreciate you guys coming on. Is there any closing remarks that you'd like to leave us with?
Speaker 2 00:49:44 Yeah, I was just going to bring in adding onto that environmental exposure. There's a disproportionate exposure to air pollution, for example. So some populations have much higher levels of exposure depending on where they live and work, which can really complicate, um, risks of developing some of these chronic lung cancer and diseases. And so thinking about solutions kind of at a bigger picture about how we can limit that exposure is going to be really important to solving some of these diseases.
Speaker 1 00:50:14 Dr. Cooper.
Speaker 3 00:50:15 Yeah. So I would like to take this opportunity to encourage people, uh, who are on the fence for, you know, getting lung cancer screening. You know, if you are in, in the highest group that I mentioned earlier, please talk to your primary care provider and, um, get lung cancer screening if you're eligible
Speaker 1 00:50:36 And about smoking cessation. That's what we're here for. Yes. Yes. Thank you both very much for coming on. I really appreciate your time. And, um, thank you again. Thank you.
Speaker 1 00:51:09 And this is Cathy I, 90.3, FM Minneapolis and cafe.org. We've been speaking with Dr. April Wilhelm and Dr. Ahmed Cole Carney, and they were from the university of Minnesota talking about the 21 policies on tobacco products pertaining to adolescents and lung cancer. If you want to be on my email list, you may email
[email protected], Charlene dollars. My research team. Thank you so much for listening. Good night.
