Tobacco Cessation

Hello, everyone. Welcome to Health Chatter. Today's show is on tobacco and some tobacco research, which, you know, it's unfortunate. I'll add this quick comment. It's unfortunate that we're still dealing with tobacco as a really major health issue. But lo and behold, it's still with us. We have a great guest with us. I'll get to her in just a second. As always, we have a great crew that makes all these shows successful and interesting. We have a research crew that includes Maddy Levine-Wolf, Erin Collins, and Deondra Howard. Our production person is Matthew Campbell, does all the logistics, the recording, and gets the shows out to you in great form with a little bit of music to you, the listening audience. We also have Sheridan Nygard with us. 

And she does some background research for us as well as some marketing. And then, of course, we have Clarence Jones, who's my great co-host and partner in crime when we do these shows. And Dr. Barry Baines, who provides us with a medical perspective on all our shows. So thank you to all of you. You're second to none. Hueman Partnership is our sponsoring organization. That's H-U-E-M-A-N Partnership. Great community health organization. Recommend that you check them out when you check our website out. Their website is huemanpartnership.org. And ours on Health Chatter is healthchatterpodcast.com. So thank you to everybody. So Clarence. You've got a great colleague that is going to be with us on this show today. I'll let you go ahead, introduce her. Thank you, Stan, for passing it off to me. We have Dr. Christy Patton. She is a licensed clinical psychologist. She's a professor of psychology and director of the Behavioral Health Research Program and the Rural Health Corps at Mayo Clinic in Rochester, Minnesota. 

She grew up in Minneapolis and completed her undergraduate degree in psychology at Augsburg College. Her research team focuses on community based participatory research to develop culturally aligned behavioral intervention for smoking cessation and other health promotion interventions among indigenous people and other communities. She is in partnership with Michelle Allen and Rachel Hardeman at the University of Minnesota. Dr. Padden co-leads a large grant from the NIH called C to Dream Center for Chronic Disease Reduction and Equity Promotion across Minnesota. Dr. Padden also served as recent co-chair of the Health Disparities Network for the Society of Research on Nicotine and Tobacco and has held many other leadership roles nationally. Now, I'm excited about this because I knew of Dr. Padden, but I had never had the chance to meet her until very recently. 

And we had a chance to sit down and just kind of talk a little bit about, you know, work and talk a little bit about community, talk a little bit about ourselves. And so having this opportunity, when I found out that she was involved in tobacco research, I felt it was a great show for us to have here on Health Chatter. Now, I want to say a couple of things before I bring Dr. Patton on. Our research team came up with two different programs. themes or two different topics to lead off our research. He says, after decades of research and proven tobacco control efforts, tobacco use has sealed the leading cause of preventable deaths and diseases in the U.S. And the second point that they made was that most tobacco products use begins in adolescence. Now, of course, that took me back because when I was younger, and I know I'm dating myself, but when I was younger, I remember the Marlboro Man. 

He'd come in riding his horse and he'd come smoking his cigarette. And I remember my father, he smoked pale milk, Paul Mall. I don't know what it was, but it was that real strong tobacco. I remember one time I took one from him and went down to the basement and I started smoking that thing and I got drunk and high as I could be. I don't know, maybe that's why I don't do tobacco right now. My friends, when I was going to school, they smoked Everybody that was cool smoked cool. My other friend smoked Winston-Salem's. And TV was just filled with people smoking in the boardrooms, smoking down the street. So tobacco, you know, as Stan, as you just said a little bit earlier, we've been talking about this thing for a long, long time, and it's still here. And then I just want to just say, I just want to ask Dr. Patton to start off with this, is this. 

When did we find out how dangerous tobacco was? There have been decades of research on that topic. I almost think about e-cigarettes and the similar stage where we're not certain about the long-term health effects, let alone the short-term health effects. Due to research, we've been conducting studies since 1960s or so on the health effects of tobacco. And I think alongside with that, the decrease in social norms around smoking as we learn more about the health effect. But the U.S. Surgeon General's report on the effects of tobacco, I think that was in the 70s. That was sort of a landmark report kind of spurring people's knowledge or awareness of the health effect. Yeah. I want to go back and ask this question again. You know, it's interesting. I, you know... 

When, you know, when we go back and you mentioned the Surgeon General's report, I can't remember, it was in the 70s sometime. But that's a long time ago. I mean, you know, and we were dealing with, you know, we identified tobacco as a major health concern. And historically, there were many, many things that were done. Like, I remember when, for instance, back then when the Twins played in the Metrodome, it became smoke-free. And there were smoke-free places that were determined. And a lot of different activities have gone on. Yet, it's still with us. I mean, and it's a major health concern. So... Have we made any strides at all? I mean, besides people knowing that, yeah, it's not good for you to smoke, but I smoke anyway. You know, I mean, what's going on here? Why is it that it's still with us the way it is? Well, on a public health level, we have made many advancements with smoke-free policies, tobacco-free campaigns, going to mass media campaigns. 

So the overall prevalence from 1950s being in the high 40s to now 12% of the U.S. population, that is an advance, but yeah, still a long way to go. And also the tobacco industry aggressively markets certain subpopulations. So within certain communities like Alaska Native American Indian communities, for example, the prevalence remain high, but within those communities, the social norms around tobacco tobacco is still more towards acceptability. And that's a result of the tobacco industry marketing certain segments, so youth. So the overall prevalence is really affected by these sub-communities that are more vulnerable to the tobacco industry. So the tobacco industry is a large force. They have a lot of money. They can make their cigarettes pretty cheaply. There's high demand. So I think overall, there's greater awareness of the health effects and the prevalence has gone down, which is encouraging. But, you know, at the same time, other tobacco nicotine products have gained in popularity. Yeah, Clarence. Yeah, no, I was going to say it's always about the money in America, right? Mm hmm. 

It's about making that money. But I think that, you know, one of the things that I want to go back, because I know that you do a lot of community-based participatory research. I want to go back to adolescence. I mean, the adolescence, use of tobacco. And can you talk about that and some of the research that maybe you've done with that? I know that you have specifically dealt with specific communities. And I'd like to hear more about what are some of the struggles in terms of those areas as well. So among youth generally in the U.S. and in Minnesota, e-cigarette use is most common, followed by nicotine pouches and cigarettes. So with youth, it's difficult because with adults, there's effective treatments. So behavioral counseling, FDA-approved medications for tobacco cessation, whereas in youth, 

Behavioral counseling, coaching is effective, but there is really at this time no evidence that nicotine patches, gum, and so on are effective for youth. So there's some limits to the treatment for youth cessation. So among adults and youth in the United States and Minnesota, Alaska Native American Indian communities do have higher rates of tobacco use. And that's the communities that I've been focusing on. And it's important to distinguish commercial tobacco use from traditional tobacco use. So tobacco is part of the culture when used in a ceremonial, spiritual way among many Native American communities. So what we're really talking about is the commercial products or commercial use of tobacco as opposed to traditional use. So a lot of my research for many years has been in Alaska, the state of Alaska, working with Alaska Native and American Indian communities there. And I was invited by the tribal leadership to focus on this issue as a key priority for the communities. So with staff, other colleagues at the Nicotine Dependence Center at Mayo Clinic, we were invited just to explore this issue. 

And people did want to partner on this. It was really important to do research. So the community identified pregnant women and youth as the top kind of subgroups to focus on. So as far as you asked about youth, and we did evaluate a culturally adapted behavioral counseling intervention, because like I said, behavioral counseling for youth is effective. But we asked youth their preferences, you know, how do we culturally adapt this? What would you prefer in a program? And the youth said they wanted to be part of an intervention where they kind of were away from their village. There was 56 villages in the region I was working in, in very rural Alaska. And basically it was a smoke-free event where we had kids stay for a weekend and there was behavioral counseling, but there was also, 

talks by elders and other community members on the impact of tobacco on their lives, but also kind of talking about what the future impacts could be. So it was very challenging, though, for that program. It wasn't very effective in terms of long-term smoking cessation, just because the kids then had to go back to their village where, as I mentioned, the social norms around tobacco use were such that There were many people, including their parents, using tobacco, so it was just really hard for them to quit. But overall, any type of behavioral counseling program that's culturally aligned has been helpful for youth to quit. But as I said, even though youth are interested in medications, there's really not that evidence yet in youth to be able to offer that to them. 

So youth cessation is very challenging. There's still a lot of calls for research on that area. So let me ask this other question. Yes, Sam. Dr. Patton, in spite of all the research talking about how dangerous tobacco use is, is it expected to grow the use? I think at least remaining stable in terms of youth cessation. tobacco prevalence rates. I think with newer products being marketed, there's a high likelihood that use would increase. I think the tobacco industry is very adept at finding new angles or new products, like these nicotine pouches that have become more popular, the second most commonly used product among youth. These products like e-cigarettes are initially kind of Word of mouth, tobacco marketing, maybe appealing to people because they're potentially safer to use because it's not a burn product or more of a combustible product like cigarettes. But nicotine pouches do contain nicotine. E-cigarettes contain nicotine. And this can lead to nicotine addiction. I don't know if you've ever known any. I'm close to a family member whose child 

used e-cigarettes and just watching that individual come off e-cigarettes, the withdrawal symptoms, very similar to what I see in practice with cigarette smokers among adults or youth. The withdrawal symptoms can be pretty severe. And that nicotine addiction in youth does predict future use. So the earlier someone starts, the more likely that they will continue use. So it's really important to prevent youth of any of these tobacco products. Okay. Yeah, Barry. Yeah. Dr. Patton, can you just help us to differentiate between nicotine, which is the addictive substance that's in tobacco products, but obviously nicotine pouches and e-cigarettes, et cetera. But between that and tobacco, because it's the nicotine addiction that that gets people hooked and, you know, having them continue to use those products. But for tobacco, a lot of the really bad health effects relate not to the necessarily the nicotine, but as you were just pointing out the burn, you know, the burn products and what that does to lung tissue and all those kinds of things. But aren't they, I mean, they're related obviously, but can you differentiate between the two? In other words, are we dealing with, 

with two different, uh, issues that we need to attack to sort of improve health overall in our, in our communities between, again, between nicotine and tobacco products, of which is more overlapped. Right. So the, the nicotine present in all of these products can lead to nicotine addiction. um which can lead to withdrawal symptoms when quitting and so forth. And also the likelihood that someone will continue use due to that addiction. Tobacco products contain the tobacco leaf. And so in those products, that is burned when using. So it's called combustible tobacco products. So cigars, pipes, cigarettes. And so how we measure their use is if you think about anyone that has a carbon monoxide detector with smoking, when we're trying to measure if someone has quit smoking, we use a little device that measures the breath carbon monoxide or the person's exposure to carbon monoxide. And it only measures recent use. So say over the 

at the most over the past day, usually within the past four hours. So those readings can be pretty high in an established um user of these burned tobacco products so um we always hear about carbon monoxide right so um if someone's leaving on a stove or burning things in their home, that is a health hazard. So this is someone who's inhaling those that burned that carbon monoxide is present And if we think about a daily cigarette smoker and the potential health effects related to that. Cigarettes also have various other chemicals and same with pipes and cigars. So with the e-cigarettes, nicotine pouches, those contain nicotine, but not the tobacco leaves. So an e-cigarette is heated and the liquid becomes an aerosol that's inhaled or vaped into the lungs. 

So that can cause irritation in the lungs, but it's not that burned product. So, you know, that's why these products are kind of thought to be safer to use. But as I said, you know, other than irritation, mouth irritation, lung irritation, coughing, headache, some people report with e-cigarettes. We know very little about the longer term effects like we do with burn products. So Dr. Patton, you talked about tobacco burn and you kind of mentioned some of the chemicals. Could you tell us what chemicals are inhaled or present when people do like a tobacco? I mean, I think people just say, well, I'm just smoking tobacco leaf. But there's some other things that are also being released at that same time. Am I correct? Yeah, I think there's 

Hundreds of chemicals, I want to say, added to cigarettes. It's amazing. Even arsenic. Just, you know, small amounts of these different chemicals. But, you know, it's like with anything with your health. If you think about food that you eat, if someone told you hundreds of additional chemicals were added to that food, that would be difficult to think about. Yeah. So let me, you know, I've got a couple of, thoughts here. You know, when we're dealing with youth i mean we we brought this up in in a previous show. And we're talking about prevention um it always dawned on me that for youth, they have this illusion of immortality. You know, it's like, okay, you're gonna tell me i'm gonna get you know, cancer or heart disease when I'm, you know, whatever age. And in the meantime, you know, 

You know, leave me alone. I like to enjoy, you know, smoking away with cigarettes. So there's that component. I'm really curious about norm changes. So, for instance, let me give you like a situation like seatbelts. I remember, you know, growing up, seatbelts weren't in our cars at all. I mean, you know, as kids, you know, we were thrown in the car and, you know, and, you know, and hopefully we were somehow or other safe. But norms have changed with regards to seatbelt usage, where people wear their seatbelts. There are laws. There are buzzers and bells in cars that remind you to buckle up. et cetera, et cetera. Now, if we look at tobacco usage, have norms changed? You mentioned that to a certain extent, maybe it hasn't gotten any worse, but it hasn't maybe gotten any better. But have norms changed around the usage of tobacco? That's my first question. Yes. 

Researchers have looked at assessing or measuring social norms and those definitely have changed. There is more awareness. So I mentioned in Alaska, I have been focusing on youth and pregnant women. And I don't know about all of you, but I think it's rare to see, you know, in Minnesota or kind of the lower 48 states, pregnant women smoking nowadays. Whereas before, Apparently in the 50s, that was pretty common. My mom talked about smoking with me and I have five siblings, so same with them. So I think it's rare nowadays to see that. Maybe in some states where it's more acceptable. And that is due to kind of that more awareness of the health effects and also stigma. So along with the social norms changing more awareness, there does come stigma, which does make it hard for people to seek treatment. Yeah. But in Alaska, you know, pregnant women are smoking and using tobacco. And it's not that there's a lack of awareness. It's more the acceptability, more those favorable social norms. So that's kind of an example I think about. 

where there have been changes in social norms. But like I said, in certain communities where there may be different social norms or the tobacco industry may be aggressively targeting certain communities. So, you know, Barry, I'm sure you can chime in on this one. But, you know, when the Surgeon General's report came out, there were, you know, connections of tobacco usage with communities cardiovascular disease, with cancer. I mean, we'll just pick those two. And I just wonder, and Barry, maybe you can reflect on this a little bit, how it is that health professionals, medical professionals grabbed hold of that information and applied it to their treatments and insights for their patients. In other words, all of a sudden, boom, we have this major thing that's connected with chronic diseases. How is it that physicians embrace that in order to help effect change around smoking? I think as a family physician, the way that played out is not so much certainly having the hammer of the information, 

that this is all bad for you. But these are kind of things, just like with youth, that it's years from now. And people are living in today, mostly, not what's going to happen 20 or 30 or 40 years from now. But for me, I think one of the biggest breakthroughs was actually more on the behavioral aspect of things, is this whole idea of... Yes, you give the information, but what's almost as important, if not more important, is to get an understanding of people's readiness to change their behavior. And there is a lot of public health work done for readiness to change. And every resident today, and certainly in primary care for sure, knows how to help assess their patients readiness to change when they identify health behaviors, not just tobacco products usage but but other things as well, because the threat of disease, that's a scare tactic, right? You want to scare people out of it. And when you're dealing with an addictive substance like nicotine scare tactics don't necessarily work very well, but trying to work on people's motivation and 

realize that it's not going to be better quit today or, you know, or else, but really that it's a process and having that relationship over time and keep checking in, keep checking in. And over time, people sort of get, you know, sort of get the message. So there's that piece from a clinical perspective. What struck me, and again, I'll ask Dr. Patton about this. I remember seeing these graphs that was almost linear. that as taxing tobacco products, the level of taxes on tobacco products go up, usage goes down. I remember seeing these, it was like, you know, taxes are going up and usage goes down, especially with youth, because they oftentimes don't have the financial resources to afford the escalating price. And that has been, you know, I mean, please correct me if I'm wrong, one of the biggest or most successful deterrents 

for tobacco product use in, certainly in younger folks and probably other populations as well. So I hope Clarence and Stan, I kind of addressed the, you know, the piece with, with how, you know, that information about health effects is just one piece of the puzzle. Yeah. And you have to have a, it's so complicated. You really need a combined strategy and it's persistence. You have to keep coming back to it. to get the message across. Just following up on that with the effective behavioral programs for youth and just delivering those programs myself to youth, the long-term consequences really don't resonate. It's more those short-term impacts that youth are experiencing. So appearance-related effects, so yellow stained teeth, breathing difficulties, like with their sports, So what you were saying, Dr. Baines, really resonated. And yes, those public health policy initiatives are super effective with taxes, raising the minimum age for selling tobacco products. And then public health mass media campaigns are extremely effective. So there's things that we can do on a policy public health level that are extremely effective. 

A question? Yeah. You know, Matthew, are you there? Yeah, I'm here. I put it in the chat here, but I was just thinking if you had any insight, kind of with as how do you expect or what do you think or what are you seeing or hearing about tobacco and nicotine use in relation to more and more states legalizing cannabis-based products? And do you think the cannabis industry is going to kind of be in direct competition with the tobacco nicotine industry? Is that going to be the next big public health problem we deal with? Or, you know, because we don't, a lot of, you know, a lot of that data still is out on long-term health effects. So I just didn't know if you had any insight to that. Yeah, I would expect that would be an upcoming major issue with the legalization. That really introduces a lot of room for potential uptake of use and or continuation of use, likely in combination with tobacco use. 

Thank you. You're a psychologist. Your background is in mental health. I remember where I saw colleagues smoking under stress. It was connected with stress. Are we still seeing that type of manifestation, the linkage between smoking and mental health vis-a-vis stress? Is that still inherent in what we're dealing with here? Yeah, so tobacco use continues to remain high among individuals experiencing mental health issues, so depression, anxiety. if they're not reporting depression, for example. And so people in practice talk quite a bit about more along the lines of stress. We might give them a questionnaire and find out they're scoring high on depression, but when people are just talking about the smoking, they talk about stress and more that it's hard to quit because of the stress that they're experiencing in their lives. 

A lot of my research has focused on people with depression, psychiatric disorders, and smoking cessation. So, for example, we had a program with women who were experiencing moderate to severe depression. And we looked at an exercise program for smoking cessation because we know from research that exercise is helpful in reducing depression. And that program was actually very effective. for smoking cessation. And it was actually a vigorous exercise program. So really high intensity exercise. So that's one example. But yeah, there's a strong relationship. I worked with a mood researcher during my, when I was getting my doctoral degree. And so we looked at just the relationships between depression and smoking. And it seems to be bidirectional where smoking can lead to depression and depression can lead to smoking. So that's interesting. But smokers, 

compared to non-smokers generally report higher levels of depression, but also anxiety, stress. So that's why there's been a lot of research focusing on mood management programs. So in my lab it was exercise, but other researchers are looking at how to manage your mood as a way to quit smoking, which is actually very effective as a behavioral program. I asked a question. I heard you mention a couple times the term safer. And, you know, you're talking about different things. And I'm wondering if safer is equivalent to being cooler when it comes to young people. You know, you hear this, okay, this is safer. Oh, so this is real cool because it's the latest trend. And I think, Bill, what do you think? Well, let me put it this way. 

Because I remember when I was a kid, when I was younger, you know, those in our community that were cool really drank, they really smoked cools because it was cool and it was menthol. You know what I mean? All those kinds of things. So our words being used to trap younger people. I mean, even today, I know that there's been a huge... there's been some efforts made in Minneapolis, in Minnesota about menthol cigarettes. So I'm wondering if we're using words now to minimize the dangers of what's really going on because, yeah, I'll leave that there because dot, dot, dot, dot, dot. Yeah, that's an interesting observation. I think these new products probably are prestigious. Cool. I haven't heard that word as much as, well, this is, 

Or e-cigarettes, for example. This is safer than smoking. Almost to the point where this is safe. And so that's made me think a lot about how do you get through to kids about the harmful effects of some of these other products like pouches or e-cigarettes. Because there's so much attention as we've been talking about cigarette smoking and its harmful effects. But I think that contributes to the normative use among youth too. They probably perceive themselves as cool with the e-cigarettes and some of these other products, but I hear more of that word about safer. Literally, I'm not doing damage to my body because I'm using these products. It's always compared to cigarette smoking. I don't know if anyone has heard of it. I'm interested in... 

In visual cues as it relates to smoking. So let me give you what comes to my mind. It's like when you see movies, for instance, where there are prisons and, you know, prisoners are smoking or they want to get cigarettes from one another. Or war movies, you know. where military, they're in bunkers or what have you, and they're sharing cigarettes or they're getting cigarettes, or prisoners of war. It's like, get me a cigarette. So I just wonder if these kinds of, and I'm sure there are many, many others, I'm wondering if these visual cues are still with us and are having an impact on usage. Yeah, I mean, the visual cues can definitely lead to a craving for a cigarette. So it's definitely true what you're saying about the importance of visual cues. 

the vaping and when my son was in high school, it was it was very easy to hide. You know, just they can put that in their pocket and kind of take it out every now and then. So, yeah, so I'm not sure how much the visual cues are kind of impacting the use right now. But certainly when it's not. in a setting where they're not prohibited from using. I could see that. I want to share a visual cue of mine. And I know I shouldn't confess this stuff, but, you know, Hill Chatter, we confess a lot of stuff. confess a lot of stuff. Okay, anyway. I try to be very sensitive to those that are homeless, you know, and you see people on the street. But one thing that I will not do now 

is if I see somebody smoking a cigarette, I won't give them no money. And I think that that's one of those visual cues for me is that hunger. And I know that many times my wife would tell me something like, well, somebody could have given them the cigarette. I said, OK, I'm not going to fight about that. But there's just something about that visual cue. And you don't have to put this in the recording if you don't want to. But it's something about that visual cue about smoking tobacco and being hungry that just, yeah, that causes me to ponder. I'll leave it alone. Okay. Yeah. It's hard because nicotine is so addicting, though, you know? Yeah. So I think, yeah, it's like if you see a homeless person drinking alcohol, you know, it's kind of that same potential feeling. Yeah. 

Yeah, I try to think about the addiction. So, you know, when you think about, okay, let's go back again to the Surgeon General's report that came out years ago. And every, you know, 10 years since then, healthy people, the objectives for the nation come out. And every year that certainly I'm aware of, There are objectives for the nation addressing tobacco usage and also prevention-oriented activities. So what's your sense, historically, I guess, You know, year in and year out, if you were to come up with a new objective for the nation, what would be on your list right now? I mean, if we're going to really make an impact, a better impact than perhaps than we've done, what objective would you, based on your research and your clinical insight, what objective would you come up with? Yeah. 

Well, I think we, as before, we can think about reducing the prevalence of overall nicotine tobacco product use. So right now in the U.S. it's about one in five adults. So we could think about a prevalence indicator, right? So maybe less than 10% for the next report or scorecard. But I also think about a major challenge that we have is that we have effective treatments. for tobacco cessation but those are really greatly underutilized so many about half of people quit smoking every year but only about 7% are successful and these treatments that we have are very underutilized sometimes people don't know about them or sometimes they're unsure like what happens if I call the quit line who do I talk to do I have to be ready to quit that day so there's all these 

thoughts about treatments that people need education on. So I would think about to enhance the success of quit attempts to, so right now about a third of smokers utilize evidence-based treatment if they undergo a quit attempt. So I would think about at least half of the tobacco users using treatment as the next target. So that's something that I've been focused on in my research is how do we enhance the utilization of these effective treatments? And so there are free treatments available too. So those are a couple of things I think about. Okay. Dr. Penn, I'm sorry for interrupting you, but you said you did work in Alaska around maternal child health. Mm-hmm. Okay. I mean, smoking around... Could you talk a little bit more about that? I mean, one of the things that I think about is that when parents smoke around the child, what was some of your work around maternal child health and smoking? Did that deter families from smoking? Was that a deterrent? Yeah. I mean, in general, with 

uh pregnant women there's some brief counseling that providers can do just to ask the woman about their tobacco use, ask about their readiness to quit, give them resources, follow up with them um so that can be helpful also and and with the clinician talking about secondhand smoke exposure and effects on children. So some of those interventions have been effective in pregnant women generally. In Alaska, we adapted that brief intervention to be culturally relevant with a lot of feedback from pregnant women. And we also had the intervention delivered by what we called native sisters or lay native elder women in the villages. And so that program was effective for tobacco abstinence postpartum. So that was encouraging. And we integrated our programs for pregnant women. We did our research within the existing health care system. So we didn't have a research building and did all this research and then get positive results and then try to figure out how do we implement this within their existing health care system. We actually did the research in the health care setting. So it's encouraging because now providers are using our materials 

promoting the use of cessation services among pregnant women. The overall prevalence, however, has not reduced among pregnant women. So women in Alaska, Alaska Native women, also, they not only smoke, they use a homemade form of smokeless tobacco called ifme. So that's really ingrained in the community. Some women think it is safer to use because they're making the product themselves and they burn a woody fungus that grows on the bark of birch trees in the area and use the ash to mix with tobacco leaves. So that's how it's made. But because the ash comes from a tree, it's perceived as safer. So again, kind of these perceptions of products being safer. So it is challenging in terms of kind of reducing the overall tobacco use prevalence. And right now, we have a program we're evaluating that is family based, recognizing, and this was actually feedback from the pregnant women. One of the challenges because of the social norms is even if the woman would quit during pregnancy, a lot of people are using tobacco around her. So their spouse, family members. And so now we have a family based program that we're evaluating at the request of pregnant women. 

to focus more not just on that woman, but those around her, and really looking at the family system. So maybe if I come back in a couple years, I can let you know how well that program worked. But what you bring up is really important, the family system and quitting tobacco, recognizing that it's just not individual determinants to behavior change. It's really these social determinants and environmental influences that we need to target. You know, Barry, you probably can respond to this a little bit, too, from a medical perspective. You know, I think of, you know, when you were speaking here, Christy, it's, you know, we as humans have these what I would dub turn-to products, you know, What do I need to do? What do I have to turn to in order to decrease my stress, decrease my anxiety, whatever? Okay. Or to be cool, you know? And, you know, think about it. We turn to things like tobacco. We turn to things like alcohol. We turn to medications. We turn to, you know... 

And meditation, you know, might be a turn to type of thing in order to decrease. So did you, you know, maybe both of you in your practices, have you seen changes in what I just dubbed turn to types of things that we as human beings turn to in order to make us feel better, in order to decrease stress, in order to whatever? Some people might say the hell with it. I'm going to go shopping for new clothes. something. Stan, I'll just be really brief here. You hit the big three. Drugs or medications. Tobacco and alcohol. Some of that is inherent in the society that we live in and they become societal norms. And I think that's what makes it a real public health challenge to do that. And I was, my ears sort of perked up, Dr. Patton, when you talked about, you know, the request for the family-based interventions. I think that's going to be, you know, the key. And just a quick aside, I remember when secondhand smoke became big, 

And oftentimes that was a much better motivator for parents to either, you know, could go to, you know, ideally to quit smoking, but as a second choice, don't smoke in the house, go outside, you know, if you want to, you know, smoke. Okay. But, but don't make your kids sick because you're smoking in the house. And oftentimes that was a motivator, you know, for parents. So again, I guess the, you know, the glass is half full, at least you help the kid out, you know, and those cues of seeing their parents smoke all the time in the house, if they're not there, it's less reinforcement of the norm of smoking. So it's, I know that doesn't really clarify, you know, things, but it's sort of like we have all the tools and, you know, we have a big toolbox and how do we deploy what's in the toolbox that works for this particular situation? 

person or this family. And a lot of times it's, for me, it was, it was trial and error, but I had the advantage of relationship over years. And, you know, so that they, you know, I'd have patients come in and say, so when are you going to ask me about my smoking? You know, cause they knew, you know, but that was good because they knew to, you know, to expect that and they can prepare their excuses, what have you, or they say, you know, I think I'd like to, you know, then invest look into that a little bit more. So it's, you have to take, like in public health, you have to take the longitudinal view. There are very few acute, you know, immediate things that you could do where you're going to see impacts. So I hope that informs the conversation a little. There are feel good things too, right? I mean, you know, just, I mean, this makes me feel good. You know, for me, it's not smoking or alcohol. It's a Snickers bar. 

I don't want to eat too many of those. But I think, you know, maybe, you know, from your perspective, you can, you know, from mental health, don't we turn to these things like smoking as crutches maybe to make us, you know, do you see more and more of that or are we seeing less of it or turning to different things? Well, I think with cigarette smoking, for example, the pandemic did not help. Oh, yeah. That's a good point. Yeah. So it was actually a growth in cigarette sales during that time. And and then people are reporting more anxiety during the pandemic. So I'm kind of stuck. There were reports of people stockpiling cigarettes during that time. Wow. So I think that didn't really if there was any decrease in some of these vices, it didn't help with the pandemic. Right. Yeah. 

Yeah, I mean, people report turning to different things to alleviate stress, one being cigarettes, alcohol. And as I mentioned, I mean, we do know from research that cigarette smokers report more stress. So there is that documented association as well. But I was just thinking about the pandemic, how that really shook things up for people. So it'll be interesting to see what the new normal is. going forward. Yeah, yeah. Well, all right. I mean, on one hand, I'm happy that we still have great researchers that are engaged in the subject of tobacco, its use in prevention. I'm happy on that hand. I'm sad that we still have to deal with it. You know what I mean? Woe these years. But it might be something that we just have to, from a health perspective, we just have to accept that it's going to be kind of around us. And it's like, how do we navigate going forward? So, Dr. Christie, last words, last comments, things that you really want the listening audience to be aware of. I think going forward, 

What I found to be really meaningful work is the community engagement in Alaska to really listen to the voices of the community in terms of their needs and priorities. And that's helped us develop some programs, many effective, some not. But even with the not ones, the community has a voice in what's the next step, like the family-based intervention. So I think about that. Although I'm focusing on Indigenous communities, primarily. I think about that with these other segments like youth and communities targeted more by the tobacco industry, communities with high tobacco prevalence. So I would encourage people, especially researchers, to think about community participatory research and how that might be helpful with the tobacco endgame. Great. Clarence, thoughts? Thank you, Dr. Patton, for Accept my invitation. I did learn a lot and look forward to working with you more on the See the Dream. Same. Thank you. Barry? I think keep working with the goal of reduction of use. I think the goal of eradication in our capitalist society where a lot of other factors are at play, eradication is not going to work just like prohibition didn't. 

really help for alcohol. But I think long-term reduction and just incrementally and coming up with newer ideas. We're never at a loss for coming up with creative ideas to try out. And then researchers like Dr. Patton can tell us if we're on the right path or not. So thank you so much for sharing your information. It was really, I really enjoyed it quite a bit. Thank you. So I'm going to link to the history And I'll reflect on Clarence's thoughts. He smoked cools. That wasn't cool. I'll leave everybody with this comment. It's not cool to smoke. It really isn't. It's not good for you. And if you need help addressing it, There are great health professionals that can help you to address the problem that you might have. So thank you for being with us. We really look forward to if there's more research coming out that you'll tap us on the shoulder and say, hey, I want to be on your show so I can tell about some new findings. So thank you so much. Greatly appreciate it. 

the work you do and your willingness to be on our show today. For our listening audience, we have a great show coming up on vaccinations. Imagine that. It's kind of like vaccination season. And so we thought it would be timely to have a show on, okay, where do we sit with all the different kinds of vaccinations? And hopefully people aren't getting kind of lackadaisical about vaccines getting vaccinated. So that will be our next show. So stay tuned for that. And in the meantime, everybody keep health chatting away.