NCTFG Podcast Episode 4 Transcript – Rachael Joyner & Jim Martin | North Carolinians for a Tobacco-Free Generation

NCTFG PODCAST EPISODE 4: From Cigarettes to Vapes: Lessons from the Past and Timeless Strategies for a Tobacco-Free Generation

EPISODE DESCRIPTION

In this episode, Rachael Joyner and Jim Martin highlight the significant progress made in supporting people on their journey to quit tobacco as well as tobacco control policies across North Carolina, including creating tobacco-free schools, banning smoking in restaurants and bars, and increasing the minimum smoking age to 21. Rachael and Jim’s work has emphasized the importance of taking a comprehensive approach to tobacco prevention and control, including evidence-based education and close collaboration with public health professionals.

Looking to learn more about the Duke-UNC Tobacco Treatment Specialist Training Program? Visit www.dukeunctts.com to access training resources and more.

Follow NCTFG on social media! @TobaccoFreeNC on Twitter, Facebook, and Instagram.

AUDIO TRANSCRIPT

[00:13] Megan Faber: Welcome to an episode of the North Carolinians for a Tobacco Regeneration Podcast. I’m your host, Megan, and in each episode, we interview an expert or professional in the field of tobacco control and prevention, asking about North Carolina policies and their work to prevent the initiation of tobacco use and to educate the public about the harms of commercial tobacco use.

[00:33] Whether you’re curious about the landscape of tobacco prevention in North Carolina or you’re well versed in this topic, you’ve come to the right place. Join us as we learn more about tobacco use and prevention and connect with local experts in North Carolina today.

[00:53] We’re highlighting the work of Rachel Joyner, a nurse practitioner with the Duke Smoking Cessation Program, and Jim Martin, the Director of Policy and Programs for the North Carolina Department of Health and Human Services Tobacco Prevention Control Branch.

[01:07] Jim and Rachel work together on the Duke UNC Tobacco Treatment Specialist Training team to offer education and evidence-based tobacco treatment for individuals and populations within North Carolina and beyond.

[01:23] Jim Martin: I’m Jim Martin and I’m the Director of Policy and Programs with the North Carolina Tobacco Prevention and Control Branch, which sits in the Division of Public Health within the North Carolina Department of Health and Human Services.

[01:38] And my role at the state level is to be a subject matter expert on evidence-based tobacco use prevention and cessation policy and programmatic interventions. And I’ve actually served in this role for the past 32 years at the state level.

[01:58] Rachael Joyner: Love that. So much experience. I think we’re such a good balance to each other because he is all just policy and wealth of information and decades of experience. And I’m very much on the treatment side.

[02:11] So my name is Rachel Joyner. I am a family nurse practitioner. I am also a tobacco treatment specialist. I work with the Duke Smoking Cessation Program.

[02:24] I see patients at Duke University Hospital. So a bunch of inpatients. We have an inpatient consult program which we kind of built and developed over the last couple of years, which is fun and exciting.

[02:37] And then I see outpatients mostly via telehealth in the Tri State area. So I have patients in Virginia and there’s a huge need for evidence based tobacco treatment there as well as in North Carolina.

[02:50] I have some colleagues who see people in South Carolina.

[02:53] And then I have the joy of being on the leadership team of the Duke UNC Tobacco Treatment Specialist Training Program, which is an awesome opportunity to kind of share, you know, some of my knowledge and experience to help kind of train other professionals around the country and other places outside the country in, you know, evidence-based tobacco treatment.

[03:16] And prevention.

[03:19] Megan Faber: Wonderful. Thank you so much for introducing yourselves. I’m so happy to have you with us today.

[03:24] Is there any sort of story that kind of led either of you to this work?

[03:30] Jim Martin: Well, I can start with my journey into public health. I was in college at the time and was actually thinking about pursuing. I was in my sophomore year year and I was thinking about pursuing a major in business.

[03:46] And unfortunately during that year, I. In February of 1982, I received a call that no student wants to receive in that, that my dad had passed away of a major heart attack.

[04:02] And he was a heavy smoker. And we had talked with him and worked with him for many years to try to help him quit. And he sought out also help from his physician but was not able to overcome the nicotine addiction.

[04:19] And because of that traumatic time in my life, I, I did a lot of reflection at that time of thinking about, you know, how could this have been prevented?

[04:31] And it led me to seek out career paths as it relates to prevention, which led me down the path to public health and public health interventions that focused on healthy behaviors and changing risky behaviors to really extend life of individuals, of course.

[04:49] And so that led me to seeking out and pursuing a bachelor’s degree in public health, then led to a master’s degree in public health and then set my career path toward public health.

[05:05] I worked in worksite health promotion to begin with the Virginia Department of Health and then landed a position with Research Triangle Institute which was focused on a research-based tobacco control program.

[05:18] It was part of a 17-community intervention that looked at interventions here in North Carolina. Raleigh was the intervention site, and Greensboro was actually the control site. So it was exciting to be a part of the largest tobacco control research intervention in the, in the world at that time.

[05:35] And that led me to, on to a state position which again I’ve been in ever since. And I think from those beginnings I have a passion for this work. It’s more than a, than a job.

[05:48] It’s always been a passion, and it’s filled with challenges every single day. And we’re trying to work to overcome those challenges. So that’s, that’s my career path thus far.

[06:00] Rachael Joyner: Yeah, I’ll share a little bit about mine. I kind of got into this work by accident.

[06:07] No one in my immediate family smokes. I actually grew up in South Florida, which as an area is kind of a very health-conscious sort of area. So, you know, in, within healthcare, you know, there were people who smoked, but it wasn’t a huge issue that I encountered on a daily basis.

[06:26] And then I moved to North Carolina in 2019. I was working at a rural clinic in Sanford. It was this odd clinic. We did, like urgent care, primary care and cardiology. It was a cardiologist who owned.

[06:42] And I was struck by that. I don’t know, 70% of our patients, and these were of every age, as young as 20s, up to 80 plus, were just smoking and smoking at incredibly high rates.

[06:58] And I was kind of taken aback because like most people, you hear, oh, the rate of smoking is down to 11.4% nationwide. This isn’t a big issue. And I’m sitting here in this clinic where 70% of people are smoking and we’re treating people for, you know, they were coming in, they were having heart attacks, uncontrolled diabetes, you know, heart failure, exacerbations, you know, asthma.

[07:23] That’s uncontrolled. And I just kept thinking to myself, we’re, we’re giving them good medical treatment and we’re, but we’re putting a band aid on these issues. You know, we would, you know, I would hear the doc and myself and the other providers I worked with, you know, say, hey, you really need to quit smoking.

[07:39] You know, smoking, if you quit smoking, it’ll make a big impact. But that was kind of the extent of the conversation. And you know, as, as I know now from working in this field that, you know, telling people that smoking’s bad for you is not enough.

[07:54] You really have to connect them with meaningful evidence-based treatment and support. And we were not doing that. So we didn’t. And I started, you know, at the time I was working on my doctorate and, you know, kind of thinking about how you can change systems.

[08:12] And so I was thinking about, you know, we have no infrastructure for treating these patients. We weren’t even doing universal tobacco screens on everybody. So really starting to think about, you know, this is an area that, you know, we can bring evidence to in a meaningful way to really change people’s outcomes.

[08:31] And I think the one patient I always think about is, I remember I was seeing a gentleman in his late 50s, nice guy, farmer. His wife was also a patient.

[08:42] She was a lovely lady. And he came into me one day for an urgent care visit. He was having rectal pain.

[08:49] And it became pretty clear to me on a quick exam, I was very concerned. He had colon cancer.

[08:55] Sure enough, got him over to GI, had a colonoscopy, he had colon cancer, advanced stage. He was a two pack a day smoker, had been since a teenager, hadn’t really ever quit.

[09:08] You know, we’d always say, hey, you know, you should quit. But someone like that, a heavy tobacco user telling them to quit without any meaningful support, they’re not going to do it.

[09:19] He died within six months of that visit with me.

[09:23] And I remember seeing his wife a couple weeks later for a, for a visit and just the devastation, you know, and, and thinking to myself, man, like this is something that you know, could have been preventable had, you know, he in a meaningful way been engaged about his tobacco use, you know.

[09:50] So I think about him a lot and that’s kind of how I got into this work.

[09:57] Megan Faber: It’s so interesting to hear like as a young professional in this field, it’s so interesting to hear how people have gotten here and the impacts that you found along the way.

[10:12] Can you talk a little bit about your goals as public health professionals to support a tobacco free generation? So thinking about kind of the younger group.

[10:24] Jim Martin: So let me just start by saying we know what works in tobacco prevention control because we have, we’re building upon 50 years of research and evidence. And so my focus is to again provide that subject matter expert from the state level, but to work specifically with state and local stakeholders and partners to really advance effective policy change at both the state level and at the local level.

[10:56] What that does is it changes social norms within the communities and provides much more of a supportive, healthy environment to be, to be tobacco free and especially work, you know, with a sense of prevention message to young people with, without for reducing initiation of tobacco use.

[11:17] So that’s really, really key. Some of the, some of the examples that I will share with you during my career is, has been working with partners, stakeholders on efforts to make our schools completely tobacco free campus wide.

[11:32] We actually worked on that beginning in around 2000 and by 2007 we had 87 out of the 115 school districts that had passed local school board policies to make their campuses completely tobacco free.

[11:48] And again think about this time. This was pre the wild wild west of Vapes at that point in time we were dealing with, with cigarette smoking mainly during that time and really trying to work on reducing smoking among youth, high school and middle school.

[12:08] So setting up a tobacco free campus was really critical to that effort. And in 2008 we worked with partners and decision makers to work with some key legislators. That was, we saw passage of legislation, it required all of the school districts to become tobacco free by August 2008.

[12:34] And so that effort, and then another huge effort that I’ve had the, had the honor of working on is making all of our restaurants and bars smoke free. That was a overall a six year effort of really working on a coalition and working and bringing in partners to convince decision makers that it was the right thing to do.

[12:58] And we actually worked very closely with the restaurant lodging association in the final year where we were successful in that effort in 2010. And so 2009 is when the legislation passed, but it went into effect in 2010.

[13:12] So that’s been a huge, I think a huge inter policy intervention within our state that’s made a huge difference in not only protecting hospitality workers, protecting families who are visiting those restaurants bars, but also specifically sending a prevention message to our statewide.

[13:35] So that’s a big effort. Other efforts have been working on tobacco free colleges and we’ve made a huge amount of progress there and especially within our community colleges where we now have 42 out of the 58 community colleges that have their campuses are tobacco free.

[13:52] Behavioral health settings is another huge area that we’ve been working on not only at the state level but now we have our site set on making all of our behavioral health centers across facilities across the state tobacco free campus wide.

[14:05] And that’s being done through Medicaid initiative that will go into place July 1st of 2025.

[14:13] That’s a huge game changer, especially working with that population group that has a higher prevalence of smoking. We’ve also worked on local, at the local level, government buildings, government grounds and enclosed public places.

[14:29] And we’ve made a lot of progress in that area. And I will say an area that we’re working and work and we need to continue making progress is making and making sure that you do not have easy access to tobacco products.

[14:44] And that’s an effort that’s been underway for many years. But now we, now we progress to the level that we need to obviously increase our age from a minimum age of 18 to 21 to match federal law.

[14:57] But that’s some of the efforts and what we’ve seen throughout those evidence based policies is that we often work with stakeholders and other partners to bring media and, and what we called finding really like media that we can advance the issue through like armed media.

[15:19] And then that word leads to the policy changes that then that drives back further demand for program services, those treatment cessation services that become as a higher demand. So the policy often drives those services.

[15:34] But I’m, I’m really proud of the work that we’ve done in these, these policy areas and it’s proved proven effective because going Back to the 90s in 1999, we were measuring smoking rates in high school at 31.6%

[15:50] prevalence in North Carolina and in middle school we were at 15% of cigarette smoking.

[15:58] I often talked about in the 1990s that this was like Joe Camel generation, which again led to tobacco master settlement agreement in 1998. And we saw the, saw that those cartoon characters and other sponsorships went by the wayside with corporate behavior change that was required by the settlement.

[16:15] And that was also a big game changer at that point. But we’re fast forward to where we are two decades later with cigarette smoking.

[16:23] We’re at 1.8%, this is 2022 data, 1.8% in high school and one in middle school. So that’s a huge change over a couple of decades that folks back in the early 2000s did not think that we could get to this level by this time frame.

[16:42] And so we’re also obviously now dealing with the whole world of vapes that came on the market early in 2007.

[16:55] And you know, again, prevalence began, we began to uptick in 2011. And then we saw by 2015, between 2015 and 2019, where we have jewel beat coming on the market and really enticing youth to use that product, we saw a huge uptick.

[17:12] So we’re dealing with a really an epidemic of youth using these types of products, emerging products.

[17:22] And that’s a whole new, and that’s a whole, it’s been a whole new world in the last decade because you know, I think we were going toward a tobacco free generation, especially a smoke free generation of youth before those products, you know, came on onto the market.

[17:40] And so we are again, we can reflect on the impact that we’ve had with cigarette smoking because we know that how dangerous that is and we know that’s going to save live lives after life.

[17:52] And but now we’re actually at the same time, now we’re, we’re directing on that success, but we’re also trying to deal with nicotine addiction from other types of products.

[18:03] Rachael Joyner: Yeah, and I can, I can speak a little bit to the downstream effect of some of this positive work. You know, Jim and his colleagues at the branch have had in the state, you know, from my experience working, you know, I see a young, a lot of young adults as well as, you know, older adults.

[18:21] And I hear this refrain like over and over and over again.

[18:25] You know, I wish I never picked up a cigarette or I wish I never picked up a vape. And that is just almost a unanimous sentiment among the People I work with.

[18:37] And so I think, you know, it really speaks to this idea that, you know, this problem of tobacco use and creating a tobacco free generation is really going to hinge on how we’re preventing youth from initiating these products.

[18:54] Because we know that the vast majority, nine out of 10 people are going to start who are daily smokers as adults start smoking somewhere between the age of 14 and 17, very common.

[19:07] And in North Carolina, sometimes that age is lower. You know, I have people who tell me they started smoking at age 8 or age 9.

[19:14] So I think because, you know, people start this habit in their teen years when, you know, their brains are still developing, they don’t understand the long term repercussions of, you know, smoking.

[19:27] I mean, I think about when I was a young teen and, or, you know, you’re not old enough to drink yet, what do people go out and do? Oh, hookah bars were really popular, right?

[19:36] And when people think, oh, I’m going to go to hookah bar and you know, sucking on some air vapor, that there’s not a recognition in your brain, you know, even if you’re a.

[19:46] I mean, I was a young, pretty well educated kid like you know, thinking about, oh, that’s tobacco, you know, so. Or vapes. I mean, there’s this perception that a vape is, you know, it’s not even a tobacco product, it’s a flavored candy.

[20:01] It’s something that relaxes me.

[20:04] So I think, you know, there’s this perception that there’s not harm there. So a lot of the work that my colleagues and I are doing are really just educating patients, educating the public.

[20:17] I’ve done this past year several kind of community forums, you know, just as a medical professional, as a subject matter expert, being able to explain the health harms, you know, of E cigarettes.

[20:31] The fact that most of the E cigarettes that people use, you know, these flavored products are not approved, are not regulated, and you don’t know what you’re getting in there.

[20:43] And so discussing through these health harms, I did a forum with local Lake county and the state. We hosted a kind of a forum for parents. And this was a Spanish language forum, you know, and just allowing parents and students to really ask questions.

[21:01] Because I think what works with youth is giving them factual information and letting them start to make these decisions that, oh, wow, this maybe is something that is not, you know, consistent with my goals and, you know, hurting the things that I want to do.

[21:19] One example was a student who, you know, after I had mentioned, you know, over the 7,000 different flavors available in vapes. And a lot of these are not studied for inhalation.

[21:30] And the potential for all these problems came up to me and said, I had no idea about that. That’s so scary.

[21:38] You know, all I ever see is online, you know, people vaping and oh, look, it’s so fun. And so. And even parents having this perception that, oh, well, at least they’re not smoking, you know, and parents themselves using vapes, you know, because you have to, you know, get the whole family on board.

[21:54] You have to look at that ecosystem that, that, you know, teen is living in. Because if they’re seeing tobacco use at home and their parents are telling them you shouldn’t do it, but their parents are also, you know, smoking or vaping, you know, that’s a problem.

[22:09] So I think that’s really key. And then the other thing, you know, when you make community smoke free, as Jim mentioned, it works. Not only are you protecting people from secondhand smoke, but you are helping people who maybe want to quit, are trying to quit.

[22:24] You’re creating an environment where it’s easier.

[22:27] One of the toughest situations I encounter in my work is working with someone who, you know, people are smoking at work, so they’ve newly quit, they go to work, they’re stressed out, and there are people on a smoke break.

[22:42] So, you know, if, if they’re in a workplace where smoking is not allowed, it creates a safe environment that’s not triggering for them. So having these smoke free areas does huge things because when you remove that temptation, you decrease access.

[23:00] People do quit and then they stay quit easier.

[23:05] Megan Faber: Yeah, absolutely. I feel like I just learned so, so much that was so informative. That was incredibly helpful.

[23:12] I’m wondering if you could speak a little bit about how your work comes together for the Duke UNC Tobacco Treatment Specialist program and how you kind of get these tidbits of information and much, much more into the hands of people across the country.

[23:27] Rachael Joyner: So, you know, are the Duke unc, and I wish in the name it also had the North Carolina, you know, Tobacco Prevention and Control branch, because that’s really what it is.

[23:38] It’s a partnership of these three great organizations, really bringing their expertise from like different corners of this problem. Right. The state is, you know, just has that wealth of experience and, you know, knowledge about effective policy, which is so important.

[23:58] You know, you can’t treat people in a vacuum. Right. And we know that these policy measures are things that are going to affect, you know, a large community. You know, creating communities where people can be Successful in staying smoke free or quitting.

[24:11] So with our program, you really get that, I think public health perspective, which is so valuable and I think missing from a lot of other programs, you know, and then, and then, and then, you know, you have the two heavy hitters, Duke and unc.

[24:25] You know, UNC has wonderful, you know, behavioral techniques and just steeped in research there. And then Duke, you know, we have a lot of drug and evidence based, you know, cutting edge treatment things.

[24:41] So all of this is coming together to really give people a complete picture of, you know, what works for tobacco treatment. Not just treatment, but also prevention.

[24:52] And the neat thing about our program is that it’s virtual, right? So it really improves access. So since our program started back in 2016 is actually when the inaugural kind of class happened.

[25:06] Since then We’ve trained over 1800 professionals in doing our tobacco treatment trainings.

[25:16] And so these are people from almost all of the 50 states. We have people from outside of the country as well. Places like Australia, Nigeria, South Africa, Israel, American Samoa.

[25:30] So that’s kind of cool that we bring people from all over for these trainings. And these aren’t, you know, not just nurses or doctors or you know, social workers. I mean, these are health educators, you know, school administrators, health and wellness coaches, an array of public health professionals, social workers.

[25:54] So it’s all kinds of different people because we don’t just need to train, you know, medical professionals, we need to train anybody who’s working in a space that’s going to intersect with tobacco use.

[26:06] So it’s kind of neat in that way that I think participants come in and they get a very well rounded view of the latest evidence based techniques for treatment and also prevention.

[26:19] And then it’s a very collaborative kind of community where we work on case studies and people learn from each other and just to hear what other people are doing. And for example, Washington state and the problems there encountering.

[26:32] So, and then, you know, once people go through this training, they’re eligible to sit for certification as a tobacco treatment specialist, but also bring that wealth of knowledge kind of home.

[26:44] And one example I will share is we have a participant. Her name is Lonnie. She actually works with the branch here in North Carolina. I think She’s a Region 2 coordinator or manager.

[26:56] And she went through our program in the fall of 2023, after that became a tobacco treatment specialist. And she recently sent us a great note. She was working, you know, as Jim does, you know, really serving as a subject matter expert in policy.

[27:12] Kind of recently spoke at a public Hearing just talking about her experience with, you know, contending with vaping in schools. And it’s really neat because based on that testimony and the testimony of others, the Henderson county commissioners kind of created this ordinance that, that dispensaries and vape shops had to be about a mile away from any school in the area.

[27:37] So, like, that’s one example of, you know, someone who gets trained and learns what works, goes back to their community, and then basically helps effect change. Right. So if a vape shop and a dispensary is not within a mile of a school, that’s a huge win because, you know, these, these teens are not going to have easy access to something that, you know, in the past might have been right across the street.

[28:00] So that’s kind of the cool thing about this program.

[28:06] Jim Martin: Yeah, I would totally agree with everything Rachel just said. It’s a world class program, had tremendous participation in the program. And I think that our tobacco treatment specialist training is unique because we do look at the policy side of things.

[28:26] And we conduct sessions, not only a general session, but also breakout sessions, where people have an opportunity to look, to put into practice some of the pieces that they’re learning about the policy process.

[28:40] And so hearing about the successes of people going back in their community and providing that subject matter expertise to decision makers, really, you know, really huge success of the program.

[28:57] Megan Faber: What advice do you have for youth and young adults who might be thinking about quitting tobacco or nicotine products and for people who might be supporting someone along their path to quitting?

[29:08] Rachael Joyner: So let’s focus first on the people who want to quit, who express that desire. Right. I think, you know, an important piece of this work is you kind of have to be a cheerleader for them.

[29:20] I think, you know, there is this perception that, you know, especially I see this in the hospital a lot when I go into a room and I say, I’m, you know, I’m with the tobacco treatment, you know, team.

[29:31] People think they’re about to get a lecture.

[29:35] Most of their encounters with, you know, non smokers and medical professionals are almost finger wagging in that you should quit, you need to quit now.

[29:45] And this is very demotivating because I think the majority of people, especially adults, understand, you know, we’ve had enough Surgeon General reports and wonderful public health campaigns for people to understand that their smoking is not good for them.

[30:02] I think the better question, and the question I try to answer a lot when I meet people for the first time is, and I, and I usually say this, I know, smoke, quitting, smoking, is one of the hardest things you can do.

[30:14] I’m here to talk to you about how I can make it easier because there are some great evidence based treatment and support options that can make you successful.

[30:25] So I think, you know, giving people hope because a lot of people, especially when they’ve, you know, smoked for a long time or vaped for a long time, they, they understand that this has a hold on them and maybe they’ve tried to quit many times or maybe they’ve not ever tried to quit because it just seems too impossible.

[30:47] So I think, you know, just giving people that message of hope that, you know, you know, encouraging. I think using motivational interviewing to start to understand their reasons for quitting, their perceived barriers, right?

[31:01] And then making it easier for them. Because when you have someone on your side cheering you on, giving you good evidence based support, it does make it possible.

[31:14] And when I think of evidence based treatment, it’s kind of two pillars you have to give people good medications. So these are, you know, the things people may be familiar with.

[31:25] Nicotine patches, nicotine gum, nicotine lozenges, These help with nicotine withdrawal.

[31:32] And then medications to help quits, things like Varenicline, which is generic Chantix and Wellbutrin. And you know, these medications, when used in an evidence based way, can really make it easier for people to get ahead of their urges.

[31:49] You know, people who try and rely, I think, and I get this all the time, people, people saying, well, you know, I just had a heart attack, I’m very motivated to quit, I’m going to go home and quit on my own.

[32:00] I’m going to quit cold turkey. And we know from a lot of research and just experience working with patients too, that only 3 to 5% of people who quit without medication, without behavior support are going to be successful.

[32:17] Which means 95% of people who want to quit and try and do it on their own are not going to have success.

[32:23] So I think, you know, recognizing that, you know, normalizing that this is something that, you know, people shouldn’t have to do on their own, it’s challenging.

[32:34] So, so I think, you know, connecting people with evidence based medications, which makes it easier to quit, but the other piece is that behavior piece and that’s the piece that gets missing sometimes.

[32:44] You know, you can’t just give people a good medication and say, see in two months, you really have to then work with them on changing their habits, their way of being, because, you know, over time smoking, vaping becomes a part of their life.

[33:00] And then you’re having to detach it. There are people who use these products to cope with stress and life situations. So, you know, in order to take that away, you need to give them other coping mechanisms.

[33:12] So that behavior change piece is what will help people stay quit for good. And so you have to have both. And I think getting plugged in with an evidence based program that knows what they’re doing, that can support you and meet with you regularly to get you through, because it’s an up and down process.

[33:29] You know, it’s not like we start medications and you quit within two weeks. For many people, it’s a journey that lasts two, three, four months. You know, I see people out to a year sometimes.

[33:41] I have a couple people I’ve been working with for a few years.

[33:44] So I think that’s important and especially for youth. I think, you know, sometimes youth are just put in this box of, oh, well, they haven’t been smoking or vaping very long, we should just tell them to quit and they’ll quit.

[33:55] Some people, and we know this, people who vape actually have a little bit higher nicotine dependence levels on average than people who smoke. So these are youth who are maybe, you know, smoking the equivalent amount of nicotine that’s in two packs of cigarettes a day.

[34:11] And they’ve been doing this for five years, you know, and they’re, you know, when I see them, they’re usually, you know, 19, 20, 21, and they have significant nicotine withdrawal if they try and quit, which manifests for, for a lot of people as severe depression, severe anxiety.

[34:28] And so you tell a youth who’s already going through a period of transition and, and upheaval and, you know, just a lot of stuff going on that, yeah, and now you have to go through intense nicotine withdrawal and we’re not going to help you with it at all.

[34:40] Like, not great. So I think, you know, just dispelling this idea that youth don’t also need some of the same support. There are situations where they should be receiving medications to help with nicotine withdrawal.

[34:53] They need that behavioral support.

[34:56] And the American Academy of Pediatrics does support that, you know, in that someone with moderate to severe nicotine dependence whose youth should get plugged in with someone who is able to consider, you know, things like nicotine replacement.

[35:12] And I think on the other side, you know, if you’re supporting someone who wants to quit, I think the most important thing is you have to be a cheerleader. You have to listen, you know, especially to youth.

[35:23] Let them talk, let them talk to you, you know, listen for their motivations and support them in whatever their goals are and cheer them on and be non judgmental. I think that’s hard for a lot of people who have not ever, you know, smoked or experienced addiction themselves.

[35:42] It’s hard to understand because it seems to defy reality, but that is the nature of addiction. And I think we need to send this message that nicotine is a powerfully addictive substance and you have to treat it just like any other addiction.

[36:02] Megan Faber: Can you talk a little bit about the policies that we’re trying to put in place or have been put in place to do this as public health professionals?

[36:10] Jim Martin: Yeah, absolutely. I think that we have to start especially with this, where we’ve been in this emerging world of vape products coming onto the market and enticing our kids with the advertising and promotion and the flavors that are kid friendly flavors and not to, not to dismiss that they, you know, there’s not a realization by youth that these have high, high levels of nicotine that can easily addict them to the product.

[36:39] So it starts a lot with, starts with many ways, with education and awareness at the community level, at the school level, at the parental level and understanding these products and, and the risk that they bring that there it’s not just inhaling water vapor, flavored water vapor.

[36:55] You know, these products are contained toxins that are really dangerous, especially when inhaled into the lungs. And you know, it also involves school leadership focusing on our, you know, our existing tobacco free policies to make sure that not only is the policy enforce, but there is a way of implementation of the policy which can be more, much more effective than suspending kids for violation of the policy.

[37:24] We, we have to realize, making sure that school leaders realize that kids are coming to school with a nicotine addiction and it’s very challenging for them to get through the school day without trying to take a hit off of their vape product.

[37:37] And so understanding and setting up educational programs that are alternative to suspension programs. We have some strong evidence based programs that we can rely upon to make sure that kids are getting help and they’re getting support and helping them to overcome their addiction and hopefully leading to successful quitting and not again just treating it as a disciplinary issue.

[38:02] So that’s really an area that we’re really a lot of focus on. Rachel mentioned parental involvement earlier. Having programs, educational programs and making sure that the parents are, you know, providing a supportive environment if their kids are using nicotine products to be helping them to discuss this issue, helping them to get help and treatment as is needed for that Community engagement is really important for especially community organizations and partners to understand the extent of the problem and what they can do about the problem.

[38:38] We talked about gave the example earlier of zoning ordinances. We have a lot of communities that are, that are specifically looking at prohibiting the locations of vape shops that are specifically setting up near schools or other community settings where you are often frequent.

[38:57] And then obviously getting youth engagement. I think that was a huge success of, for our efforts in reducing smoking is that we were able to utilize funds from the Tobacco Master Settlement Agreement at that time to really get youth really highly engaged in educating not only their peers, but also educating the community about the issue.

[39:18] And that’s one thing that we are working toward with the new settlement that we have from that the Attorney General was able to achieve through a lawsuit with dual labs, we have a dual settlement that at the state level we’re using those funds to focus on effective tobacco prevention and cessation for youth and young people.

[39:43] So that’s an effort that we’re beginning to build up now as to. To get more youth involved in building off of our work for the North Carolina Regeneration Program. Another area that youth have been engaged in and also communities have been engaged in is making sure there’s awareness at the local level that we need their support and their voice to reach state lawmakers, to increase our.

[40:10] Strengthen our state law, to increase the age from, from 18 to 21 for the purchase of these products as well as to have other evidence based policy efforts that go along with that law to make sure that they align with federal law and that the enforcement of that law can be much more effective.

[40:31] So that’s another area that we are working on that again will bring more community wide efforts to support those individuals who want to quit and help prevention as well. Of course.

[40:47] Megan Faber: Yes, definitely. I’m curious if over the course of the past 30 some odd years, have you seen a shift in these types of priorities? Like have we always been focused on education and awareness?

[40:59] Or do you think that may have been different in the 90s or so when you were dealing with more cigarettes than vapes?

[41:06] Jim Martin: You know, it’s.

[41:08] They’re very, it’s very similar in dealing with what we would consider an epidemic of cigarette smoking back in the 90s and where we were dealing as we were dealing with an epidemic of vape product use and now, and so using very similar evidence based strategies that have been shown to be effective with reducing cigarette smoking now have to be applied to the vape products as well.

[41:33] So anywhere we’re Having smoke free policies. We’re also looking at tobacco free policies which includes e cigarettes within those areas. So I think that again it’s, it’s making sure that policymakers understand the extent of the problem and you know, and understand that the policy is a solution to this problem and looking.

[41:57] And also you have to, a lot of times that people have to look through a different lens. I think as Rachel said earlier, are these really truly tobacco products and understanding that they’re delivering these high levels of nicotine which again affect the developing brain of youth and making sure that they understand the extent of risk and public health danger that these products present to our young, young people.

[42:24] And again, we are, we’re, we are, I think we’re set on the right track now to follow again the policy efforts that led to reducing cigarette smoking that now will over time will reduce and reverse this course of a product use in our, in our state and in our country.

[42:44] So I’m still very optimistic that we can get toward that goal of, of having a tobacco free generation. We have to be on the outlook though at the same time of products, you know, and industry reinventing products that come, that may come on to the market that may again use similar techniques of advertising and flavors and different types of strategies to addict young people because that is a, you know, they’re often obviously the market target for these products.

[43:19] Rachael Joyner: Yeah, and I will piggyback on that point that Jim made. Something I’m seeing more in my practice with younger patients, especially you know, these young adults, is this emergence. And we, and we know from you know, recent state data, as far as, you know, the National Youth Tobacco Survey, that nicotine pouches are, you know, getting much more popular.

[43:43] And so you might have heard the probably one of the most popular brands uses Zen heavily kind of on social media, TikTok, you know, people really, you know, popping up somewhere and I think, you know, what was the light bulb for me.

[43:58] I had heard patients talking about it, had, you know, done some reading about it. But we were at a provider meeting and somebody mentioned nicotine pouch or Zen and one of the other providers who’s a wonderful tobacco treatment provider, you know, for cigarettes and other things, is like, oh, what, what’s that?

[44:14] You know. So like Jim said, staying on top of and you know, alert about these products because, you know, I have people come to me, oh, my friend said that Zen’s a great way to quit the vape.

[44:27] You know, isn’t it like nicotine replacement? Isn’t it kind of like, you know, nicotine Gum or lozenge. So, you know, explaining to people that, you know, this is a tobacco product created by a tobacco company and their aim is to have repeat customers.

[44:45] These deliver high levels of nicotine because most of them use nicotine salts which are absorbed much more quickly and readily into the body. Right.

[44:55] And so these are not a safe way to quit smoking, you know, or quit vaping, you know, pointing people. This is a tobacco product. You need to use an evidence based, FDA approved, You know, there’s a reason it’s FDA approved, it’s gone through testing and it’s, you know, shown to be effective in helping people quit.

[45:15] So I think countering some of these things as they pop up, as Jim said, the way, the way vaping did, I mean, you know, I think we haven’t mentioned this yet, but E cigarettes have been the most popular product used by you since 2014.

[45:30] So it’s been a decade that these are the most popular products. So obviously this is something you really need to put our sights on and you know, doing everything within our power to, you know, counter this new kind of threat.

[45:43] I think.

[45:47] Megan Faber: Absolutely, yes. And with that to kind of close us out, what do you think individuals can do in their communities to help further these policy goals to help people in their communities kind of work towards the tobacco free generation?

[46:06] Jim Martin: Again, I think it comes down to working to make sure that communities are aware of these problems.

[46:15] I can remember presenting to a huge group, parents and healthcare providers and school leaders and asking them, are you aware of the product Juul? And people are like, what product?

[46:28] What are you talking about Juul?

[46:30] And again, it was on the market and it was beginning to again something. If that same room was filled with youth and I asked the same question, everyone would raise their hand.

[46:42] Yes, I know what a jewel is, I know that.

[46:45] So I think becoming, making sure that from a parental perspective or community perspective that you’re aware of the changing market.

[46:54] Now we have products like Geek Bar and we’ve had Elf Bar and we’ve had Lost Mary and other types of E cigarette products that are coming on the market that are now addicting youth and also understanding that these have very high levels of nicotine and nicotine salts, which often hides the harshness.

[47:17] It changes the PH level, it changes the harshness of these products being used by youth. And so therefore there has to be much more community awareness in education again at the community level, the school level, parental level, community engagement in knowing what are evidence based policies that can work in their community and what needs to happen at the state level so that they can educate and advocate for those types of changes.

[47:44] Because once we get those types of policies in place, it’s going to have again, a much more healthy environment. I think that knowing that FDA is also working at the federal level along with again our partners at the CDC for, you know, a national level work on this, on this effort is also important to know that federal, state and local communities can all work together in, in unison to really have a tobacco free generation.

[48:16] Rachael Joyner: Yeah. And I’ll just add that, you know, one thing I think on a, from a provider perspective is being able to knowledgeably answer people’s questions when they come up. And one that comes up a lot, you know, is just educating people about the addictiveness of a vape.

[48:33] I think, you know, it’s purposefully vague about how much nicotine is in a vape. Right. So, you know, people will come to me, young adults who are like saying like, hey, I go a whole week and use this same vape.

[48:48] Right. So I must be doing pretty good. You know, I’m not going through a pack of cigarettes a day. But truthfully, with the, with the, you know, increasing amounts of liquid in these vapes, you know, these vapes that are bill does, oh, it’s a 9,000 puff vape.

[49:03] Well, what does that mean?

[49:05] These often have, you know, 12 to 16 milliliters of liquid in them and that is the equivalent, and it has the equivalent amount of nicotine to about 28 packs of cigarettes.

[49:18] So if, for example, just to make the math simple, say 21 packs of cigarettes, if someone is going through that in seven days, you know, they’re having a three pack a day smoking nicotine habit with these vapes.

[49:31] And every time I tell that to someone, they are shocked. They have no idea. Many of the healthcare providers we teach in tts, when we explain how to figure out the nicotine content in a vape, they are floored.

[49:45] So I think just bringing that awareness or from a flavor perspective, we all know there’s a lot of information now about the addictiveness of using a menthol based tobacco product and how it makes, makes nicotine more addictive, makes it harder to quit.

[49:59] Well, when it comes to vapes, they’re not going to label it as a menthol vape. It’s going to be a grape ice or a strawberry ice. So if you see a vape flavor that has the word ice in it, ice equals menthol.

[50:12] And so, you know, I, I often tell people switch to, you know, when we’re working on trying to quit switch to a vape product that does not have ice in it because ice is meant the and so it’s a lot of that sneaky stuff that from a, you know, a healthcare provider or somebody providing information to public, arming them with that knowledge so they can make smart decisions because there’s just, you know, if you don’t know, they can’t do anything to change it.

[50:40] Jim Martin: And we’re all building off of one another, you know, working together to get that information out. It’s really critical.

[50:52] Megan Faber: As we wrap up today’s episode, we want to thank Jim and Rachel for joining us and talking about how we can support a tobacco free generation through both prevention and treatment.

[51:01] Our conversation doesn’t end here, though. If today’s topic was particularly interesting, or you have thoughts, stories or questions that you would like us to explore in further episodes, please reach out and follow NZTFG on social media.

[51:14] You can find us tobaccofreenc on Facebook, Instagram X and LinkedIn. You can also visit our website that’s linked in the description below to get updates on upcoming episodes. This podcast is supported by the North Carolina Department of Health and Human Services Tobacco Prevention Control Branch and the University of North Carolina’s Tobacco Prevention Evaluation Program.