Episode 21

Tobacco, Nicotine and the Lesser of Two Evils

We all understand the dangers of smoking—but the debate over vapes, nicotine pouches and other tobacco alternatives rages on: Can vaping really save lives? Or are nicotine alternatives a slippery slope: a dangerous gateway to lifelong substance use? Professors Jasjit Ahluwalia and Jennifer Tidey have spent their careers researching and fighting the global scourge of tobacco-related diseases and fatalities. The two public health professionals discuss their takes on a harm reduction and how it applies to the modern nicotine landscape.


Welcome to Humans in Public Health. I'm Megan Hall.

In the past few years, the field of public health has become more visible than ever before, but it's always played a crucial role in our daily lives.

Each month we talk to people who make this work possible. Today, Professor Jen Tidey and Dr. Jas Ahluwalia from the Brown University School of Public Health.

If you’re a smoker, chances are, you’ve tried to quit. It’s clear by now that smoking is bad for your health, but, what if you can’t kick the habit?

That’s why some public health experts- like Jen Tidey and Jas Ahluwalia- are trying a different approach- instead of asking smokers to quit, they’re helping them get their nicotine fix in less harmful ways.

Jas Ahluwalia started thinking about tobacco use back in medical school, when his student organization invited a special guest speaker.

Jas Ahluwalia 0:55

We invited C. Everett Koop, who back then was a Surgeon General. He dealt with AIDS, and he dealt with cigarettes and I was his host. And so there's a picture of me sitting in the middle, the Dean of the School of Public Health and C. Everett Koop sitting next to me, and he signed it. He wrote “To Jas for your part in the tobacco wars.” And I had done absolutely nothing related to tobacco cigarettes, and it was sort of a prophecy or something. And here I am, you know, 40 years later doing work in that space.

Narration: 1:21

Jas got interested in researching tobacco cigarettes years later, while he was treating patients…

Jas Ahluwalia 1:27

And I realized that tobacco, along with alcohol, physical inactivity, a few things were all the things I was seeing as an inpatient physician at Grady Hospital in Atlanta.. I just thought to myself, we could prevent many of these hospitalizations or at least delay them.

Narration: 1:42

Jen took a different path to Tobacco research…

Jen Tidey 1:45

I come to this work as someone who was interested in dopamine, I studied cocaine and amphetamine in graduate school, and I came to nicotine later.

Megan Hall 1:52

you know, cigarettes versus cocaine. I mean, one is something that for a while was sort of generally accepted versus, you know, an illegal substance. So, yeah, how was that research different?

Jen Tidey 2:03

Surprisingly, not all that different. There are a lot of similarities neurochemically, behaviorally. It’s not a stretch at all.

Narration: 2:10

In the beginning, Jas took a fairly traditional approach to helping people quit smoking.

Jas Ahluwalia 2:15

Which was abstinence, quit, you know, nicotine replacement therapy, these medications to help people quit smoking, there was counseling, cognitive behavioral therapy, lots of voodoo, no seriously,

Jen Tidey 2:26


Jas Ahluwalia 2:26

Acupuncture, lots of different things that people could use.

Narration: 2:30

But some of his colleagues were trying something different- encouraging smokers to use e-cigarettes.

Jas Ahluwalia: 2:36

I was like, what's all this e cigarette stuff. I wasn't doing it. And, and then serendipitously, I was working with my grad student and we did a clinical trial, a small one.

Narration: 2:46

This trial gave smokers training and tools to try switching to e-cigarettes. At the end of six weeks, they found that those smokers still took in the same amount of nicotine, but they were exposed to fewer cancer-causing substances. And about 25% percent of them had already stopped smoking traditional cigarettes.

Jas Ahluwalia 3:04

And I began to realize, in my opinion, that this is probably the biggest game changer that I've seen in my 30 years,

Narration: 3:13

Jas was starting to embrace an approach that public health experts use to address other risky activities, like drug use, sex, and even driving -- Don’t focus on stopping it entirely, focus on making it safer.

He thought- why not use this approach, called harm reduction, for smokers?

Megan Hall 3:30

So Jen, Could you explain a little more about what this harm reduction strategy means for cigarettes?

Jen Tidey 3:36

Yeah so most people who smoke want to quit, but quit rates are very low. It's very difficult to quit smoking, I've had family members who tried to quit. And you know, my stepfather ultimately died from smoking, unable to quit. So harm reduction is an approach that says, Okay, You're not ready to quit or you can't quit. Let's switch you to a product like E cigarettes, which are less harmful.

Narration: 4:01

By pinpointing what makes smoking so dangerous, they can come up with alternatives to keep smokers safer.

Jas Ahluwalia 4:07

So cigarettes combust. And so anytime anything goes into combustion, coal, cigarettes, it releases a lot of carcinogens, volatile organic compounds and other carcinogens that cause cancer. You know, the end of a cigarette, when lit is approaching 600 degrees centigrade. That's Neapolitan pizza temperature. So it cooks a pizza fast. An e-cigarette is not lit, it's not combusted at all. So it's dramatically safer, because it doesn't have the 70 or so carcinogens, or co-carcinogens, and tumor accelerators, all these bad things that cigarettes have.

Narration: 4:42

This harm reduction model is still controversial, but Jas says we use harm reduction more often than you might think.

Jas Ahluwalia 4:48

I can give you a list of 30 things that we practice every day in harm reduction. Seatbelts helmets, Condoms, opioids, the list is huge. If you have diabetes, you might take one bite of a dessert, not order your own dessert. The list just goes on and on. So we all do it. Sometimes people will tell me, Well, I don't believe in harm reduction, I go “yeah you do.” So what it is, is I think there's something unique about tobacco versus like even methadone. People just vehemently– there's a vitriolic hatred for the tobacco industry, because of all the things they lied about. And just It was unbelievable what they did.

Narration: 5:21

But this distrust of the tobacco industry means that there’s some major misconceptions about smoking alternatives.

Jen Tidey 5:28

Harm reduction in the form of e-cigarettes is something that people are very confused about right now, because many people think that nicotine causes cancer, when it's actually, you know, as we've been talking about, it's the combustion, it's burning stuff, and sucking, those toxicants into your lungs. It's not the nicotine that's causing cancer.But if we can find a way to break through that confusion, it's a strategy that could really help people.

Megan Hall 5:53

So how do you balance trying to discourage teens from vaping, new smokers from vaping versus encouraging cigarette smokers to vape? That seems like a complicated message.

Jen Tidey 6:06

That's the crux of it right there. You know, It's a nuanced message. The media messaging that we've been getting about E cigarettes for at least five or 10 years has been, nicotine is terrible for you, you know, you look at the FDA communications that it's like a parasite it gets into your brain. Now, how do you back up from that? And say, well, actually, if you don't smoke, don't start using E cigarettes. But if you are a person who smokes, you should switch to E cigarettes. I think of like someone came up to you and said, “Should I eat a hamburger from McDonald's every day?” I would say, “No, you should not eat a hamburger.” But if they said, “well, actually, I have a Big Mac every day. Should I switch to a hamburger?” I would say, “Yeah, less special sauce, no bread, no, you know, all that stuff. That's probably a better approach for you.” And then, at some point, you can, you know, maybe drop the burger.

Narration: 6:59

Jas’s research has shown that getting smokers to switch to vaping is a great way to reduce cigarette use. He’s started teaching this tactic to people he meets every day.

Jas Ahluwalia 7:08

there's a guy who works at Brown,

He was smoking a pack a day, … And he's a super nice guy about 30, 35

Narration: 7:15

He wanted to quit, so Jas told him about e-cigarettes. And how they could provide the same nicotine that smoking did, while also being safer.

Jas Ahluwalia 7:23

So got him on the e-cigs, he came down to seven cigarettes a day for weeks, which is harm reduction. Right? So I said, You know what, I have an idea, throw on nicotine pouches.

Narration: 7:32

Nicotine pouches are small packets that get placed between your lip and gum. They supply nicotine like a cigarette, but they don’t include tobacco and they don’t combust either.

Jas Ahluwalia 7:42

And when he did, he got down to three cigarettes a day, And I saw him yesterday, I said, How you doing? And he said, Doc, I'm down to 0. I've done it and it just made my heart– We just saved a life. He's got a seven year old son, we just saved someone's life. And so when people get vitriolic about E cigarettes and things like that, it's committing homicide, by not allowing this to be available to smokers. The people who make policy are rich, upper middle class, people who make policy for people who have the illnesses and in situations like schizophrenia, dual addictions, mental health disorders.

And then we're worried about rich kids who are using E cigarettes, but not about these people who are dying from combustible cigarettes. So I will go down fighting on this topic until I die myself on harm reduction.

Narration: 8:50

Jen approaches harm reduction from a slightly different angle, She’s looking at making cigarettes less addictive:

Jen Tidey 8:56

The FDA has within its authority, the ability to reduce the nicotine content of cigarettes, to a very low level, a minimally addictive level. And I've been working with groups across the country, to do research to provide the scientific evidence that this is a policy that would actually help people quit smoking. And there have been numerous now randomized clinical trials. And these are in people who are not actively trying to quit smoking, that if you randomly assigned them to cigarettes with very low nicotine content, they reduce their smoking by about a third. And they don't experience a lot of craving. They don't experience a lot of withdrawal. They reduce their tobacco toxicant exposure, and they reduce their cigarette dependence. We've seen it in adults without psychiatric disorders, in adults with schizophrenia, and people with other mental health conditions like depression and anxiety.

Megan Hall 9:50

So what is the likelihood that we'll get to a point where all cigarettes will be low nicotine or is that even possible? Like is this a policy change that needs to happen?

Jen Tidey 9:58

It would be a policy change, it would be implemented by the FDA. We're sort of waiting. Of course there will be lawsuits. But, you know, I'm hopeful. I think Jas and I are both optimists. Scientists, we have a long perspective, these things take a long time. But I'm really hopeful that yes, that the FDA will reduce the nicotine content and cigarettes, that alternative products will be available for people to switch to, and that this will have a profound, positive public health effect.

Megan Hall:

What's your hope for 10 years in the future for the state of smoking and tobacco use?

Jas Ahluwalia:

I think what's gonna happen domestically in United States is a prevalence of smoking will continue to fall. And we'll reach that level where you're less than 5% prevalence and you're considered a smoke free society. So I think we're gonna get there to hell or high water, either through things like a menthol ban, which is already being fought low nicotine content, cigarettes, which is also going to be fought e-cigarettes and pouches, which are being fought, you know, but the trains left the station, and I think I feel very hopeful for this country.

Megan Hall:

What about you, Jen? What do you see 10 years in the future?

Jen Tidey:

I feel hopeful, I don't know if we'll be there in 10 years, but I do think in 20 years, we'll be at less than 5%. We're already seeing that in youth. It's less than 3% cigarette smoking. So I think we'll get there. If the FDA can take the steps that it needs to take, reduce the nicotine content of cigarettes, maintain the availability of appealing non combustible alternatives, put out an effective media campaign just to straighten out the confusion that is now in people's minds about nicotine versus tobacco. I think we'll get there. Yeah.

Megan Hall:

Well, Jas and Jen, thank you so much for joining me today. This was really interesting.

Jen Tidey:

Yeah. My pleasure.

Jas Ahluwalia:

Thank you very much. Appreciate it.

Jen Tidey is the Associate Dean for Research and a Professor of Behavioral and Social Sciences at the Brown University School of Public Health. She’s also a Professor of Psychiatry and Human Behavior at the Warren Alpert Medical School

Dr. Jas Ahluwalia is a Professor of Behavioral and Social Sciences at the Brown University School of Public Health, and a Professor of Medicine at the Warren Alpert Medical School.

Humans in Public Health is a monthly podcast brought to you by Brown University School of Public Health. This episode was produced by Nat Hardy and recorded at the podcast studio at CIC Providence.

I'm Megan Hall. Talk to you next month!

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Humans in Public Health
Conversations with Brown University School of Public Health researchers about their work, and what's new and next in the field of public health

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