Clearing Away the Smoke About Cigarettes with Matthew Carpenter, PhD

One of the hardest addictions to manage or quit is smoking cigarettes. The CDC’s latest analysis notes that smoking-related illness in the United States costs more than $300 billion each year, including nearly $170 billion for direct medical care for adults, more than $156 billion in lost productivity, including $5.6 billion in lost productivity due to secondhand smoke exposure.

So what should we do to address this health and economic concern? Why are cigarettes still readily available and so addictive? And how do we help those who want to quit and have not been successful or encourage loved ones to quit who continue to smoke while suffering its deadly effects?

Dr. Matthew Carpenter is a professor in MUSC’s Department of Psychiatry and Behavioral Sciences. A clinical psychologist with a PhD from the University of Vermont, Dr. Carpenter’s research interests relate to tobacco use across a broad methodological continuum, from lab-based studies of craving and nicotine dependence to small and large-scale clinical trials for smoking cessation, to public health policy for effective tobacco control. He has led multiple studies and trials on smoking cessation and alternative tobacco products.

Read The Transcript

[00:00:01] Loretta Lynch-Reichert: Hello, everyone, and welcome back to MUSC's Science Never Sleeps podcast. I am your host, Loretta Lynch-Reichert. One of the hardest addictions to manage or quit is smoking cigarettes. Perhaps one of the reasons for this is the fact that cigarettes, known carcinogenic products, are still legal and socially acceptable to purchase and smoke, albeit in narrower confines than previous eras. The CDC's latest analysis notes that smoking-related illness in the United States costs more than $300 billion each year, including nearly $170 billion for direct medical care for adults, more than $156 billion in lost productivity, including $5.6 billion in lost productivity due to secondhand smoke exposure.

So what should we do to address this health and economic concern? Why are cigarettes still readily available and so addictive? And how do we help those who want to quit and have not been successful or encourage loved ones to quit who continue to smoke while suffering its deadly effects? Here to chat with us about this problem and to offer some understanding is Dr. Matthew Carpenter, professor in MUSC's Department of Psychiatry and Behavioral Sciences. A clinical psychologist with a PhD from the University of Vermont, Dr. Carpenter's research interests relate to tobacco use across a broad methodological continuum, from lab-based studies of craving and nicotine dependence to small and large-scale clinical trials for smoking cessation, to public health policy for effective tobacco control. He has led multiple studies and trials on smoking cessation and alternative tobacco products. Welcome, Dr. Carpenter.

[00:02:00] Matthew Carpenter, PhD: Well, thank you for having me.

[00:02:02] Lynch-Reichert: Our pleasure. So before we get in depth in the myriad factors related to cigarette smoking, I'd like to ask you to explain the difference between a few of your research foci. Specifically, what is the difference in research goals for tobacco control, smoking cessation, and nicotine dependence? Are they related? And why not just focus on smoking cessation?

[00:02:26] Carpenter: Well, we could, that's a very easy question and a natural question. It really depends on what you are studying and how. So for example, if I'm studying nicotine addiction, I'm studying the process by which smokers become addicted or their addiction or dependence changes over time. It's more mechanistic than anything else. If I'm doing clinical trials that are focused on cessation, then it's about quitting smoking and ways to do that, how it happens, how it may not work for some people and more so for others. And if I'm talking about policy, then I'm really talking about population surveillance and populations at large. So, really, it's all under the umbrella of smoking cessation, but it's really about where our focus is and what we call it.

[00:03:17] Lynch-Reichert: And that makes sense, because sometimes you have to really understand the mechanisms before you can even offer solutions to smoking cessation or even talk about alternative products.

[00:03:25] Dr. Carpenter: Exactly right, so we don't do clinical trials until we are understanding the processes of addiction and what it is that keeps people maintained on nicotine, cigarettes or e-cigarettes or anything else, and it's that kind of science that leads the way for clinical trials. And then once we know what works in a clinical trial, then we can apply it to the population.

So we can have policies that deliver these strategies to people at large.

[00:03:52] Lynch-Reichert: Is it fair to call smoking addiction? When I think of addiction, just as a layperson, I think of things that are, to me, really horrible, like drug and alcohol addiction and things that can really devastate a life. Smoking, indeed, causes, as we noted earlier from the CDC, many medical problems, but it's not one of those things that can ruin your life, at least in the short term. What are your thoughts on that?

[00:04:20] Carpenter: Yeah, so, addiction is sort of-- has gotten a pejorative interpretation in our culture, pejorative meaning that it's got a negative stigma. So the word that I prefer is "dependence."

[00:04:35] Lynch-Reichert: -Okay.

[00:04:36] Carpenter: It's a dependence, and it's not implying anything that's a character flaw, which we sort of have the word "addict," right? You're an addict, you have a character flaw of some sort, and we want to get away from that and not stigmatize anybody, so I prefer the word "dependence." But really, we're talking about being hooked on nicotine. Now, what is dependence? And is it an addiction or is it a habit?

And what I would say, it's both. And this is really easy to explain and I think most smokers would understand, so when you smoke a cigarette, the addictive property, if you will, the dependence-causing property is the nicotine. It's in your brain within seconds. It's releasing dopamine and a cascade of other neurotransmitters that makes you physiologically dependent. It's an addiction, it's a physiological dependence. If you don't have that nicotine, you crave, you go through withdrawal, you have urges. Now, if that was all that dependence was, if it was just a physiological addiction to a drug, then we could treat that drug, that dependence in a pharmacologic way.

[00:05:50] Lynch-Reichert: Mhm.

[00:05:51] Carpenter: But let's face it. This is an example I often use with smokers. I said, "Raise your hand if you ever have a cigarette when the phone rings. Raise your hand if you ever have a cigarette when you get in your car at the end of the day." And of course, I go through this with many people and the room fills with arms in the air. So, why is that? It's because it's a learned behavior. The phone rings, automaticity. They get in the car at the end of the day, the automaticity of reaching for that cigarette. It's not like you have a thought process that says, "Oh, the phone is ringing. I think I'm gonna have a cigarette right now, 'cause I've had 20 years of this and this is what I typically do." No, it's an automatic learned behavior. If you think back to your Psychology 101 days, it was like the Pavlov dogs. It's the same process.

So, is it an addiction or is it a habit? And the answer is it's both. So it's a behavior that we've learned and it doesn't unlearn itself overnight. So, by extension, there's no silver bullet for quitting smoking. If I quit yesterday, does that mean I don't have urges today or tomorrow or next week or next year? Because those associations linger. The phone is still gonna ring. I'm still gonna get in the car at the end of the day and those cravings are gonna kick in because of what I've learned over many years of use.

[00:07:15] Lynch-Reichert: That's a very good point. It really brings up a good visual of this addiction, this dependence, if you will. Well, I'd like to speak a little bit more about that, actually. Not the definition, but what is happening in the brain when you smoke cigarettes?

[00:07:34] Carpenter: Yeah. So, the nicotine, when you inhale a cigarette, or inhale any drug, I mean, it reaches your bloodstream very quickly, within seconds. It crosses into the brain within seconds. And it's releasing a whole cascade of neurotransmitter effects. The biggest one, of course, is dopamine, and dopamine is that "feel good" neurotransmitter. It's the neurotransmitter that's released when other drugs of abuse are abused. So, cocaine, heroin, other things are releasing the same pharmacologic effects, and that is reward. That is the "feel good" sensation, and if you think about a pack-a-day smoker. Okay, think about a pack-a-day smoker. That's 20 cigarettes a day, and let's just say that you have 10 puffs of a cigarette. That's 200 puffs a day of immediate, constant, without-fail reinforcement, okay? And if you want to acquire a drug dependence, that's a pretty good recipe for success there is to deliver a drug in a way that has multiple times-- hundreds-- without fail, instantly gratification. And that's how dependence is created.

[00:08:53] Lynch-Reichert: I understand that one of your recent research projects looked at how a patient coming in for a physical or other healthcare was asked by their healthcare team if they smoked and wanted to quit. But it wasn't a good track record when you were observing this. Would you tell us about that project?

[00:09:10] Carpenter: I'd love to, and actually, it has a long background to it. So, about 10 years ago, I got fascinated in this idea that we need easy, pragmatic tools to get smokers further engaged in the quitting process. Okay? So, I can wag my finger at you and say, "Loretta, you really need to quit smoking," and I could persuade you and control you and all those things, but chances are you're going to get frustrated, I'm going to get frustrated, and we just know that words don't always work, okay? So what can we do for those situations, particularly if you may not want to quit smoking? Okay, so I got fascinated in this idea. What can we do for smokers in an easy, scalable, pragmatic way that even smokers who don't want to quit might be a little bit receptive to? So I got stuck on this idea of medication sampling. Now, what does that mean? So, medication sampling is exactly what it sounds like. I give you a sample of a product to use as you wish, in any way that you want, and it's not meant to replace treatment. It's meant to start treatment as a catalyst for it.

So again, even if you're not interested in quitting smoking, if I give you this tool, maybe it's a way for you to say, "Huh, I'll try, I'll give it a whirl. This guy just gave me a free thing. There's no commitment to it. I'll just try it, see what I like about it." So that was the flavor of the intervention and we did several trials of medication sampling, and we measured a whole range of things. Does it lead to continued use? Does it lead to quit attempts? Does it lead to cessation? Do you like the product? All those types of things. The outcomes from those studies were generally pretty favorable. So, it wasn't a panacea, it wasn't a silver bullet for smoking cessation. It doesn't have like huge success rates, but relative to our control groups, we did pretty well. Again, we're just engaging people in the process, even among people who told us at baseline, "I don't want to do this so much." Fast forward in time. So, I was thinking, "Well, how can I-- what is the best application of this medication sampling idea?" If you're gonna do this in the real world, where would you do it? Okay, so this is a true story. Sitting in my dentist's chair and finishing up my dental visit, and what do you leave from the dental visit? You leave with a baggie. What's in the baggie? Well, your toothbrush and your toothpaste and some floss and all that other stuff. Why do they do it?Well, they do it for marketing, of course. They do it for oral health, of course. And is it an easy intervention? You betcha, it takes about 30 seconds to hand over a bag. Is it a scalable intervention? Well, what does that mean? Meaning that it doesn't take a lot of cost to do, it doesn't take a lot of training to do, not a lot of instructions that you have to give. You just hand over the bag.

So from that dental experience I thought to myself, "Well, hm, what would happen if we did the same thing? "So, we did that and we did that in primary care throughout the state of South Carolina, and this is going to your question. So we did that throughout the state of South Carolina with 22 primary care clinics. Half of them were randomized to a control group that just got brochures and pamphlets, ways to quit smoking, and the other half got the same brochures, the same pamphlets, but a little starter kit. A little kick starter of medications, nicotine patches, nicotine lozenges, those types of things. Then we measured the outcomes of everybody for the next six months. Again, did you use it, did you like it, did you go out and buy more?

And by the way, did you change your smoking behaviors? Did you try to quit? Did you succeed in quitting? Did you fail in quitting? And again, we found, just like our earlier studies, that this idea of medication sampling is a way to catalyze and kickstart the cessation process even among smokers who at baseline told us, "Uh-uh, I'm not ready to do this. I can't do this. I don't think I have the tools." Even among those people at baseline who said--

[00:13:28] Lynch-Reichert: "Forget about it," yeah.

[00:13:29] Carpenter: "Forget about it," yeah. Even when you give the bag to those folks, they'll run with it. Now, again, is it a silver bullet for smoking cessation? No, it's not, but it's a 30-second intervention. I didn't have to train the doctors to do it. I gave them the dental analogy and they got it. They understood. That was the extent of my instructions to them. Remember the dentist. And it's inexpensive. It doesn't cost a lot of money to buy these medications, at least for a two-week starter park. So, it was, in my view, scalable, pragmatic, immediately actionable. A person could go home that day and use it, okay? And it's concrete rather than me wagging my finger at you and saying, "Loretta, you gotta quit smoking." Now I'm giving you a tool to do so. So, yes, it should help the smoker. Now I am circling back to your question. So it should help the smoker, but it should also help the doctor, because now the doctor has something that she or he can do rather than just wagging the finger and saying, "You know, you really should quit smoking. We've had this conversation 10 times before. You're rolling your eyes; I'm rolling my eyes." Not that all doctors do that, but now we've given the provider something to do, something to give out. "By the way, I want you to-- I'm going to give you this bag and it's free. Do with it what you want." Now we're empowering the smoker to make his or her own choices about the goals and pace for cessation, if any. It's not shoved down their throat. It's empowering them.

[00:15:00] Lynch-Reichert: Right.

[00:15:01] Carpenter: So it is theoretically sound. It makes sense. So yeah, I was really excited to do this, and we did notice an effect that it gave the doctors a little bit better way to manage their patients. They know it's hard. They feel powerless to address it, et cetera. Ironically enough, that story sort of ends by a study that we're about to do. I'm not doing it but some colleagues of mine up in the Northeast and Midwest are doing that study in dental patients.

[00:15:31] Lynch-Reichert: Oh, no kidding.

[00:15:32] Carpenter: Yeah, yeah, yeah. So I'm a part of that study. I'm happy to be a part of it. They've reached out to me and it'll be an exciting study to do. We're not quite there yet, but same concept. Providers in the dental clinics should be doing the same thing for their smokers.

[00:15:48] Lynch-Reichert: Well, it's interesting. So I presume you guys published about this research and I'm dying to hear if more-- across the country-- more primary care physicians or health care workers are doing exactly what you suggested from your study.

[00:16:04] Carpenter: Well, it's hard to know. You know, I don't want one study to change practice and have a complete paradigm shift. I'm not so bold as to say that this one study is going to change how everybody does smoking cessation in primary care. I want them to pay attention to it and if they think it has value to them, then I think it's advisable to use. We're working on a secondary analysis from that same trial where we do long-term cost effectiveness. In other words, if this intervention costs me $80 to deliver, what kind of savings is that going to have for you if you quit smoking long-term? Cancer risk, cardiovascular risk, et cetera. A simple $80 intervention, it may not have a drastic effect on cessation. It has an effect but it's fairly small, but is it going to change health outcomes and quality of life? So we're working on those analyses now.

[00:17:09] Lynch-Reichert: Well, it's interesting because I know that in the state of South Carolina, state employees actually have to tell our state health insurance whether we smoke or not. So there's--I wonder, again, because smoking is a dependence tool, how you... I'm thinking about health economics. I don't know if you've ever been engaged with that, but it's interesting to see, does the patient take a look at the cost benefit analysis from paying extra for insurance-and is that an incentive?

[00:17:44] Carpenter: Right. So how is a smoker, a consumer, going to weigh all of these values? The cost of using this medication, the cost of continued smoking, the unknown effects if I continue to smoke on my children and will they pick up smoking? I don't know how much the average consumer is making those calculations. I don't know that. All I want them to do is have pause and say, "This is something that I can do." Most smokers know that smoking's bad.

[00:18:26] Lynch-Reichert: Right.

[00:18:27] Carpenter: Most smokers have desire to quit. They just feel frustrated in prior attempts. They feel that they can't do it. They're on a roller coaster of a short-term success and long-term failures. So how do we get them off of that rollercoaster with an actionable tool? So we're just trying to get people to make smarter quit attempts sooner.

[00:18:50] Lynch-Reichert: Sure, sure. That makes perfect sense. As an academic health center, we know that clinical trials are a very important tool in research. Because cigarettes are such an addictive product, what methods do you and your team employ to encourage participation in the research?

[00:19:02] Carpenter: Wow, it's such an important question and there's no easy answers. I mean, participation in clinical research is a challenge for any clinical researcher, not just the tobacco people and ourselves, my team. We want to get more people into our studies. We want to get more diverse groups into our studies. Let's face it, smoking these days is becoming increasingly concentrated among certain segments of the population. There are racial differences, there are socioeconomic differences, and there are certainly urban and rural differences.

Okay? In fact, the smoking prevalence in Charleston Country where we are is quite low compared to the rural outreaches of South Carolina. There's a large discrepancy.
So if I sort of wave my research flag and say, "Please come join my study," that's gonna be really insufficient because I'm gonna get the people who may not be the people who really need it. How do I go out to the community and get the people who really need it? So I'm really excited by some of the work that we're doing on what we call remote clinical trials. Remote clinical trials are exactly what they sound like. So rather than me doing a research study at the Medical University of South Carolina and hoping and crossing my fingers and expecting people to come into my clinic, we're going out to them so that they don't have to leave their living room, okay? Now wouldn't that be nice if you live in the middle of nowhere South Carolina? So how do I reach those folks? We have to be able to go out to them and specifically, to their living room so that we can deliver treatment in that way? So I'm really excited by the methods that we're doing with this. My colleague, Dr. Jen Dahne, and I are really expanding the options and the methods by which we reach out to smokers around the state and we are figuring out how to do consenting -over the internet.

[00:21:08] Lynch-Reichert: Sure.

[00:21:09] Carpenter: We're figuring out how to do treatment delivery through the phone and apps and the mail, of course. We are figuring out how to do follow-up assessment on your iPhone or your Android device or your iPad. We are figuring out how to collect biospecimens remotely. That's a big challenge for us.

[00:21:27] Lynch-Reichert: Is this all--can I ask, did this idea happen prior to COVID or was it a--

[00:21:28] Carpenter: Excellent question, so, yes. So, my studies have always been fairly large in size and Charleston's just not that big of a town. So you can't get 600, 800, 1,000 smokers very quickly in Charleston. That's a good thing for the prevalence of smoking in Charleston, but if you need that size of a study, you've gotta go elsewhere. So even prior to COVID, we were going out remotely. And so I mentioned Dr. Dahne. We're working with others in our group to really push this science forward. We have a very large center grant that we're working on where the whole crux of it will be delivering treatment in a way that is remotely. And Dr. Ben Toll is a big partner with me on that one, among many others. So we are delivering treatment out into the living rooms of participants around the country. And--so, two things I want to add to that. We can increase, if not ensure that we get demographic diversity, geographic diversity. So we don't just have Caucasian women joining our studies, which was a problem 10 years ago. So, we can get more numbers of men, we can get more numbers of African American smokers, we can get more rural smokers, which are--those three groups-- if we could do that, we're doing a good thing. COVID comes along and forces the entire universe to shift from in-person to remote studies. So we were bragging like, "We've been doing this for a long time. You know, catch up with us, folks." So we actually became a national resource for a lot of people who wanted to shift their science to remote, and we were getting phone calls and emails all the time. "Well, how did you guys do this, how did you guys do that?" And it turns out we were able to give a lot of, I hope, good answers for other researchers as they wanted to do the same thing. Now, COVID is on its way out, knock on wood, or we hope. So should we go back to in-person research and go back to where we once were three, five years ago? And I would say no. I would say that we still need to be going out into the rural areas of South Carolina and elsewhere to reach our study populations? We live in an ivory tower in academia, right? And we have to be very aware of that, and to recognize that the research that we're doing needs to and has to be applicable to large segments of smokers, even if they don't live in our proximity. So I think there's great value to doing remote trials well beyond COVID. Is every clinical trial going to be a remote trial? Absolutely not. You know, sometimes you need to come to the lab. Sometimes there's an intervention that we need to have more on hands on, not hands off. But to the extent that we can, can we--how can we be extending our research beyond these ivory towers?

24:34 Lynch-Reichert: So I'm going to show my nerd creds here, because what I'm curious about when you're doing those remote research trials, is a lot of what you're getting back as evidence just self-reported stuff? How do you get actual evidence that you can say, "Okay, this is valid and accurate"?

24:54 Dr. Carpenter: Excellent, okay. That's the big... -$64,000 question. -$64,000 question. That is the one that we're scratching our heads about, honestly, because when we do clinical research for smoking, for years we have relied on what we call "self-report." You're a smoker--I know you're not a smoker, but, Lynch-Reichert, I ask you, "How many cigarettes have you had," and you give me a number. -"Have you tried to quit?" -"Yes." "How long have you stayed quit?" All the things that we ask you, we rely on your self-report. Some studies, there might be monetary incentives to be quitting, okay? Suddenly, now you've got some bias there. And just in general principle, we want to have an objective measure by which we can corroborate your self-report, okay? How do you do that remotely?

Well, we're working on it. We are getting to the point now where we can deliver to the smokers' homes a small device called a carbon monoxide detector. It's a one-time use-- it's a single-user use, you can use it repeatedly, and it'll connect to your phone. And we have ways of you breathing into this device and us capturing the data remotely in real time, so now we have an objective indicator of your smoking through carbon monoxide. Can we be doing other things? Yes. Should we be doing other things? Yes. We're on the cusp of really changing what's possible remotely. And maybe one day we'll be able to capture other biometrics through sensors, watches that you may wear, and capturing those data in real time in an objective way.

[00:26:34] Lynch-Reichert: That's fascinating, and I bet you that there's somebody out there doing an app or some sort of device that will come on the market soon for you to do just what you're trying to do.

[00:26:40] Carpenter: Right, so we are, MUSC is, I think, leading the way in that regard for the breathalyzer that I just mentioned. I mentioned Dr. Dahne a few minutes ago. I'll mention her again. She is working on the app that will integrate data collection and the device itself in a way that's very research-friendly.

[00:27:01] Lynch-Reichert: That's really cool, and it also suggests to me that the type of research that you do, and I'm sure this is true about a lot of addiction research, but you're not just dealing with the very specific smoking clinical trials. It sounds like you're talking about having to engage neurosciences, engineering, of course behavioral, which is your forte. It sounds like there's a whole lot engaged here to actually do a clinical trial that might actually offer solutions. Is that a fair assessment?

[00:27:37] Carpenter: Sure. Yes. Throughout all these tools, using these tools, you have to figure out how will people use it? What things are they paying attention to on the screen? How will they understand it? So, there's a lot of sciences that are sort of lateral to us that we rely on to help us develop these tools even better. I mean, even graphic artists. We need to develop an app that is easily understood, navigable, those types of things. You can't just develop these things in a silo and just hope that people will use them.

[00:28:15] Lynch-Reichert: Right, absolutely, and that's one of the great things about an academic health center, the kind of research we do and the folks we have at our disposal from across the institution, different disciplines and that sort of thing. It's really a wonderful thing. What are some realistic solutions that your research has teased out about smoking?

[00:28:36] Carpenter: Okay, so... So this hearkens back a little bit to what we were talking about a few minutes ago. If you think about the strategies for smoking cessation, they actually haven't evolved a whole lot in the past 20 years.

[00:28:53] Lynch-Reichert: Really?

[00:28:54] Dr. Carpenter: The newest medication for smoking cessation is varenicline, it's been around for 15 years.

[00:28:58] Lynch-Reichert: Wow!

[00:28:59] Carpenter: There is a new tool called transcranial magnetic stimulation. That's basically a neural treatment and that's been developed here at MUSC through Dr. Mark George and Xingbao Li and others. And they are really pushing the forefront in terms of how that can be administered, not exactly remotely because it involves TMS, but in terms of behavioral treatments, we're also developing new tools there. But going back to my medication sampling work, our work, my work has been mostly about taking existing treatments and expanding the ways that we can...

[00:29:44] Lynch-Reichert: Engage people?

[00:29:45] Carpenter: So, I'm not so much changing the tool as much as I'm changing how many people, what types of people are using that tool.

[00:29:50] Lynch-Reichert: Okay, that makes sense.

[00:29:51] Carpenter: Yeah, so, now I will say that we are really working with some exciting new research here in terms of psychological research on memories, memory reconsolidation for smoking cessation. Dr. Mike Saladin, he's the national leader in this. We are doing some mindfulness work to change how people view reward that they get from smoking, and that's a project that we work on with Dr. Brett Froeliger who is a close colleague of ours. And, together, our group, our smoking cessation group is really moving forward with a large, concerted effort to develop these strategies and to disseminate these strategies in a real-world context.

[00:30:39] Lynch-Reichert: That's wonderful. That's really good. You know, I didn't even ask you, but over the years, have we seen a decrease in smoking?

[00:30:50] Carpenter: Yes.

[00:30:52] Lynch-Reichert: Overall? In every age group, every gender?

[00:30:53] Carpenter: It's going down in every demographic, it's just going down differently.

[00:30:54] Lynch-Reichert: Oh, how so?

[00:31:00] Carpenter: So, the people who live in rural areas, the decrease is lower. African Americans, the decrease is lower, meaning shallower, it's not decreasing as quickly. Other disenfranchised groups. LGBTQ populations have very high rates of smoking.

[00:31:16] Lynch-Reichert: I didn't know that.

[00:31:17] Carpenter: Yes. So there are pockets of underserved populations, under-resourced populations, where it's really becoming almost a tragedy how they're getting left behind.

[00:31:33] Lynch-Reichert: Oh, but good thing we're doing the research that might change that.

[00:31:35] Carpenter: We really need to be reaching out to these people in ways that I've talked about a minute ago.

[00:31:41] Lynch-Reichert: Okay. That's fascinating, it really is. What are some healthy alternatives if you're not going to quit? I mean, as a researcher, what are some healthy alternatives to smoking?

[00:31:50] Carpenter: Okay, so the only healthy alternative you have to smoking is quitting smoking. That is the only thing that is going to markedly change and improve your health is to quit smoking and quit smoking entirely. Many smokers continue to struggle with that for reasons that we've noted before, dependence, multilevel forces of dependence. So what are we to do? So, you might be... I'm inferring through your question through alternative products out there that are alternative to combustible cigarettes. So let's just talk a little bit about that. Alternative to combustible cigarettes: e-cigarettes, electronic cigarettes, and then there's a new class right now called heat-not-burn products. These are products that are non-combusted, okay? Right off the bat, you're not combusting anything and you're not inhaling that smoke, okay? You're inhaling a vapor.

Big difference, okay, so one is combusted and one is not. Okay, so when you are inhaling a smoke, you are taking in carbon monoxide, you're taking in tar and all the other nasty ingredients of a cigarette, many of which we know cause cancer, heart disease, and other outcomes. Along comes e-cigarette, electronic nicotine delivery system, sometimes called ENDS, electronic nicotine delivery system, and they vaporize nicotine without burning it. So it's a vapor that you inhale. It is nicotine that is getting into you and not necessarily all the other carcinogenic ingredients from a combustible cigarette. Is an e-cigarette safe? No. There are known toxicants in e-cigarettes, but, generally, those levels are very, very low, often called trace levels of toxicants in an e-cigarette. Are they safe? No. Are they safer than combustible cigarettes? Absolutely. And I would say 95% of researchers would agree with me on that. There is a few holdouts on that. So, safer, but not safe.

So, can smokers use these products as an alternative? Yes. It's certainly better than continued smoking. Okay, certainly better than continued smoking. We've got to be careful of dual use, people who are using both products. I use combustibles in the morning, I use electronic cigarettes in the afternoon. And that's somebody who may eventually quit, and now they've got an alternative to maybe use both forever, and, that, we've got to be very cautious of. So we are doing trials here at MUSC... ...mechanistic studies in the lab. Dr. Tracy Smith is doing a lot of studies around the constituents of an e-cigarette, the vice characteristics of an e-cigarette that smokers do or do not find palatable and will make them switch or not switch. So she's doing a lot of lab-based studies. I myself am doing clinical trials where we test giving out the samples, if you will, where we give out samples of e-cigarettes or not e-cigarettes, and we see how smokers respond to them. Do they like them? Do they not like them? Same thing that we did for the medication samples. We're doing clinical trials of e-cigarettes in that vein, too.
And, then, on the population level, we have people like Dr. Mike Cummings, who is an international expert in policy around e-cigarettes and alternative products in general, how they should be regulated, what kinds of restrictions we should have around them in terms of flavors, pricing, marketing, et cetera, that get them into the hands of people who can benefit from them, smokers, and keep them out of the hands of the people who should never be using them, non-smokers and adolescents, okay, because that's a big dilemma.

[00:35:49] Lynch-Reichert: Lot of controversy there, yeah. Is nicotine a carcinogenic?

[00:35:53] Carpenter: No. So that's the issue. Nicotine by itself is... I got to be careful what I say here. Relatively harmless, okay? The analogy that I often give, and I know it's not a perfect analogy, it's like caffeine in soda. Does it have an effect on you? Yes. Cardiovascularly, you might get nausea if you have too much of it. You might have a headache if you get too much of it. You'll certainly have heart racing palpitations, okay? Sweating might be another one if you have too much of it. If you have too much caffeine, if you have too much nicotine, you're going to feel it. So it's the addictive dependence-causing property of a cigarette, but it's not what's causing the harm. What's causing the harm? The tar, the other toxicants in a cigarette. So that's the whole point of-- let's go back to nicotine replacement products like patches, lozenges, gums, those types of things, NRT, nicotine replacement therapy. That's all they are, they're replacing the source of nicotine in a cleaner format. Same principle with the e-cigarette. It's a cleaner delivery vehicle of nicotine, which is what your body is dependent on, but without all the same levels of toxicants and other harmful ingredients. So it's just replacing the source of where you're getting it through a cleaner delivery system.

Now, what separates e-cigarettes from the other existing products like gums and patches? There's lots of things. I'll focus on two. Okay, so the nicotine replacement therapy, patches, lozenges, gums, those are approved cessation products, meaning that they've gone through the FDA review process and have gotten an approval as a cessation tool. They've got approval as a cessation tool and they're approved as such. E-cigarettes are not. They never went through the FDA as a cessation tool, so they cannot claim on their boxes "these will help you quit smoking." Okay, they're not allowed to say that because they're not approved in that way. Can smokers use it for that purpose? Absolutely, I kind of hope they do. So they have different levels of regulatory approval. The second thing I'll point out is a distinction between the two groups, either electronic cigarettes or nicotine replacement patches and lozenges, is just the efficiency of the nicotine delivery. If I put a gum in my mouth or if I put a patch on my arm, the nicotine is delivered very slowly, okay? Very slowly as compared to a combustible cigarette which is in seconds, okay?

Then along comes an e-cigarette and delivers it, and you're inhaling that vapor deep into your lungs and you have nicotine delivery that is on par with what you might get from a combustible cigarette. So now you've got something that's a lot more substitutable for a combustible cigarette because merely it's delivering a lot of nicotine fairly quickly. And, then, it's also the habit part... The hand-to-mouth part, that habit, what we sometimes call the sensory motor substitution, you feel that burning in your throat. You don't feel burning in your throat from a patch. There's a lot of aspects about an e-cigarette behavioral substitution, sensory motor substitution, nicotine pharmacokinetics of delivery that approximate a combustible cigarette in ways that a patch does not. Does that mean that we go out there and argue that people should be using e-cigarettes for smoking cessation? Can't say that because they're not FDA-approved for that purpose. So what I say to smokers in a very practical way is, "Look, first off, quitting smoking is the very best thing that you can do for your health, period." Quitting smoking, quitting smoking entirely is the very best thing that you can do for your health.

[00:39:46] Lynch-Reichert: And that of others?

[00:39:48] Carpenter: Right, exactly. And there's lots of FDA-approved smoking cessation strategies. Nicotine patch, gum, lozenge, inhaler, nasal spray, varenicline, bupropion, these are all medications that are FDA-approved for smoking cessation. At which point, someone will say, "Well, I've tried that and I've tried that," and if that person is going to go back to combustible cigarette smoking, at that point, I might have a side conversation: "By the way, let's talk now about e-cigarettes because they're certainly better than what you're doing now."

[00:40:15] Lynch-Reichert: That makes sense.

[00:40:16] Carpenter: So I wouldn't make it as a global message for everybody to hear because you don't want that message to get out there that e-cigarettes are safe and everybody should be using them. I don't want adolescents to get that message. But for the smoker who is otherwise unable or unwilling to quit through strategies that we would first advise, well, then let's go to plan B.

[00:40:37] Lynch-Reichert: Sure. It's interesting. So, that kind of goes to my next question, is how would you counsel a parent whose child has begun to smoke cigarettes?

[00:40:38] Carpenter: So that's a tough one because--and I'm a parent, too. My oldest is in high school, so this is an issue that we talk about. First off, parents should be concerned. They should be aware of what their kids are doing, right? That's simple parenting 101, right, is ask questions. And this is another thing that I think is important, is people think they've had the conversation with their child and then they're done, right? They can check the box. "I don't need to do that anymore. We've already had that conversation." No, you have to have-- this is a repeated conversation. What might apply in 9th grade is different than 10th grade, different than 11th grade, and certainly different than 12th grade. So, you know, you've got to have the conversation repeatedly and in neutral ways. You know, I think kids are worried about, you know, "My parents are going to yell at me. I don't want them to find out." But parents were once kids too and they know exactly what it's like to be a teenager and an at-risk adolescent. Obviously, a parent should be talking to their adolescents about vaporized nicotine e-cigarettes because at that age group, electronic cigarettes are far more common than our combustible cigarettes.

[00:42:04] Lynch-Reichert: Oh!

[00:42:05] Carpenter: Yeah, we've done a great job with getting cigarette smoking down, but e-cigarette use is escalating. There's a lot of things that affect adolescent uptake, you know, peer pressure, you name it. So I think parents should be having that conversation. They should be having it repeatedly in as neutral ways as possible and as non-threatening ways as possible. So, try to avoid yes/no questions. "Who do you see using it?" "Where do you see it being used in your school?" "Are people asking you about it?" "What questions do you have?" That's always a good one, it's like, "What questions do you have? Because I know if you're not seeing it yet, you're going to. You're going to. And how do you navigate that temptation?" The other thing I'll say real quickly is nobody ever starts out cigarette or an e-cigarette and says, "I want to use these the rest of my life."

[00:43:00] Lynch-Reichert: Right.

[00:43:02] Carpenter: Right, name me one person who said that "I'm going to use these the rest of my life because they look great." Nobody has that as an intention. They're going to try it for a little bit. They'll dabble, they're going to try, and guess what? A little bit of dabbling here, a little bit of use there and, suddenly, we have that dependence kicking in, both physiologically and behaviorally, okay? So there is no switch that says, "Yesterday, I was non-dependent and today I am." It's a gradual onset. And you don't suddenly wake up and say suddenly, "Wow, I'm smoking earlier in the day. Wow, I'm starting to crave more than I ever did. I am using in places that I didn't think I would be using in the past. I'm starting to hide it a little bit more. Uh-oh, I was not doing this three months ago." And so you got to ask yourself, "I'm starting to show addiction, dependency," you use the word, but now might be a time for a little bit of self-reflection, say, "Gosh, I never intended to get this far. And before I'm using this for the next 20, 30, 40 years of my life, maybe I need to re-evaluate this now." Right.

[00:44:11] Lynch-Reichert: When you see the commercials on TV-- and I love these commercials, I think they're very profound and very visual graphically-- about the folks who've been smoking and the horrors that have occurred to them for prolonged smoking, do those have any effect?

[00:44:28] Carpenter: Yeah, so I have to confess, I don't follow the literature on a daily basis on this. You're talking about health warning labels. There's a great researcher at the University of South Carolina, Dr. Jim Thrasher, who studies this all the time, and we've worked with him in the past, and what I've learned about health warning labels is those graphic warning labels are things that are quite-- it's called the "ick factor," the icky stuff, they work. They have an effect to the extent that there's something actionable at the end of it. So maybe here's the picture and now here's the number for the quitline or here's what you can do. So rather than just sort of paralyze people in fear, but we give them a-- Okay, now I've sort of scared you, but now let me give you a tool to act on.

[00:45:13] Lynch-Reichert: Yeah.

[00:45:16] Dr. Carpenter: Maybe it's not just giving the quitline, but resources for other cessation support things. So we have to give smokers the tool. We can't just sort of paralyze them in fear and hope for the best.

[00:45:28] Lynch-Reichert: That makes perfect sense. Two things: one, what do you see the future of cigarette products? And the last thing I'd like to leave with our listeners is something actionable. How can they get engaged in the clinical trials regarding smoking cessation, mechanisms, whatever, with you guys? So let's start with that first one.

[00:45:54] Carpenter: The landscape of tobacco products is constantly changing, and it's a challenge for researchers because we're trying to keep up with the science. And short little side story, we might design a study today. In five years from now when the study results are done, it may be based on a product that is now yesteryear, right? So constantly keeping up with the evolution of products is a big challenge for us. We know that alternative products are here to stay. They will grow in sophistication, they will grow in marketing appeal, they will grow in variation. There will be many more of them, different ways to tinker and play with them. They will be more modifiable by the part of the user to change different settings of those types of things. So, we have to understand them. Will we say as a group that all of them will be safer than cigarette smoking? I think that's a big leap to say that statement. As long as something is not being combusted, you're reducing harm. So we want to get people off of combustible cigarettes. That is the big goal here, is to reduce the burden of combustible cigarette smoking in favor of any harm-reduction strategies that can do that, as long as we pay attention to the potential negative consequences, and there are a number, adolescent uptake being the biggest one.

So these products are here to stay, and we've got to embrace that and to understand that and keep the science on pace with that. Your second question, what can smokers do? Well, if you live in the outlying areas of our university, you can always call the state quitline. Every state has a free, anonymous-- or I should say confidential resource that you can use from your living room as much as you want, and they will guide you through the evidence-based practices of smoking cessation, both medicinally through medications and behaviorally, and they've got great tips and tricks for you to do so. Many quitlines, including the South Carolina quitline, give out free medication, so back to medication sampling again, right?

So, not everybody is eligible for those programs, but many smokers are. And, then, I would always check out the MUSC website to find out what options are available. We advertise our studies and what's available. Some involve coming into our lab. Many of our studies do not involve coming into our lab. Some of our studies are treatment-focused, and some of these studies are more mechanistic in process, understanding the mechanism and the process of smoking. So you don't necessarily have to want to quit to join these studies. And so we'll take them all and we will try to find a study for everybody.

[00:48:43] Lynch-Reichert: Okay, and we will make sure to put on our-- when we push this out to you, all of our great listeners, we'll make sure that there are some resources there where they can find out about the studies you guys are doing and about all the studies at MUSC.

[00:48:55] Carpenter: Great, thank you.

[00:48:56] Lynch-Reichert: Thank you so much, Dr. Carpenter, for your time and for the work you do, your team, your academic collaborators across the country. We're really grateful to you. And you're a lot of fun to talk to.

[00:49:12] Carpenter: Thanks, I enjoyed this, I really did.

[00:49:15] Lynch-Reichert: Thank you, it is great fun. And thank you to all of our listeners for your continued interest, engagement, and support in research happening at the Medical University of South Carolina. Stay healthy and informed, and quit smoking if you're smoking.