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November is Smoking Cessation Month - a reminder to raise awareness about the harmful impact that smoking has on people’s health, particularly when it comes to cancer. It’s also Lung Cancer Awareness Month, but smoking can cause cancer beyond just the lungs - it’s also a significant risk factor for esophageal cancer, pancreatic cancer, bladder cancer and many others.

Thousands of people take the first step to a healthier lifestyle during the annual Great American Smokeout, which falls on Thursday, Nov. 20, this year. The Great American Smokeout challenges people who smoke to refrain from cigarettes for 24 hours with the hopes that this will inspire long-term goals to quit smoking for good.

We sat down with Caroline Cobb, Ph.D., member of the Cancer Prevention and Control research program at VCU Massey Comprehensive Cancer Center, as well as an associate professor and director of the Health Psychology program at the VCU College of Humanities and Sciences, to learn more about the dangers of smoking, the benefits of quitting, and why smoking cessation is essential to improve health outcomes and lower the risk of cancer.

How did your interest in health psychology and tobacco use begin?

I've been studying tobacco use since I was an undergraduate student. Thanks to a psychology professor who took a chance on me, I really fell in love with tobacco research and understanding addiction. I was smoking at the time, which was quite interesting. I definitely felt some guilt around that when I was talking to people, trying to help them quit, and studying the harms, which I certainly knew about, but I continued to smoke until I was in graduate school. I've been focused on this field for more than 20 years.

I continue to be motivated to address the leading cause of preventable death in the United States, which continues to be tobacco use. It harms every part of the body. There are all these newer products that we know less about, like electronic cigarettes, nicotine pouches, and heated tobacco products. But the number one killer remains smoking products. The death and disease they cause far outweigh these other products, and although we certainly still need data and research on them, I think a lot of our efforts should be on smoking products.

What brought you to VCU?

I grew up not too far away from here in Powhatan County, Virginia. I was looking for a Ph.D. program focused in biopsychology, and I met a faculty member named Thomas Eissenberg at VCU. He was doing exciting work, researching some novel tobacco products, like hookah. I came here for my training, and I had the best experience: incredible mentors and fantastic access to researchers and different fields. After I got my Ph.D., I went to work for a non-profit called The Truth Initiative in Washington, D.C., which does a lot of tobacco prevention and policy work.

Lucky for me, a position opened up here at VCU, and I was so thankful to have the opportunity to come back. I had such a great experience and so many existing collaborations and connections that the transition was really seamless. I felt really supported, and I have continued to feel like I've grown into this home, even more now as an associate professor.

What inspires you to do this work?

My trainees, my students, undergraduates, graduate students and postdoctoral fellows. They really inspire me to look at the research in a different way. Watching them grow, sharing my experiences and how I've succeeded or failed, and how that's worked for me, is also very rewarding.

But also, I’m inspired by my community and the people that surround me, not just here at VCU. I live in Richmond and I'm connected to several community-serving organizations. The one I work with most closely is Henrico Too Smart 2 Start, a youth substance use prevention coalition. Working with them, I can better understand the impact of substance use on multiple levels and contribute to efforts to help our community members make good choices.

What are the dangers of smoking?

We continue to understand more about how tobacco use harms almost every part of the body, especially when smoking tobacco. Cancer, particularly lung cancer, is one of the deadliest consequences of smoking. There are also oral cancers, and that's not exclusive to oral tobacco, but smoked tobacco as well. Cardiovascular harms to the heart are another major cause of death.

Infertility is another danger that many people don't think about as much. Pregnant women who smoke are a high-priority population. We don't have many optimized treatments for these women, but we know how important it is to reduce harm to the developing baby.

What are the benefits of quitting smoking?

There are benefits to quitting smoking at any age, at any point in someone's smoking journey, and no matter what stage of cancer someone is in.

Even 24 hours after quitting, we see a drop in the risks related to heart attacks for people who smoke. Within 48 hours, small changes begin in your taste and smell, because those cells start to recover. In 2-3 weeks, people are seeing positive changes in blood circulation, lung health and extended benefits in other body systems that take more time.

Do you have any advice for someone who wants to quit smoking?

Having social support on your quitting journey is really important, and that can look very different for different people. Some people might have a trusted partner, friend or family member. Sharing that you're about to do something really hard, and knowing that those folks are there with you, can be very helpful. One of the most important predictors of a successful quit attempt is having that social support.

Quit attempts are just as important as long-term quitting. It takes time and practice. I tried to quit probably hundreds of times until it stuck. For people who have been smoking for 20 years or more, it's a really tough habit. It's ingrained, it's a piece of their daily routine, so sometimes people quit in certain spaces first. Maybe it's in the car, after meals or during the day.

Can you speak to the differences between traditional smoking tobacco products and newer products like vapes and e-cigarettes?

It's nuanced. I'll focus on electronic cigarettes, or nicotine-containing vapes. People call them lots of different terms. They've been on the market for a little less than 20 years now in the United States, but we still don't know much about long-term health effects. Another issue with vapes and understanding their health effects is that they are very diverse, unlike a cigarette, which is more of a standardized product. There's less variability in cigarettes than when it comes to vapes. Vapes come in various nicotine concentrations, and the liquids inside the products are also variable in what they contain. The amount of nicotine that you can get, which is going to relate to nicotine dependence, or how likely someone might be to get addicted, also varies. The evidence around their harms is starting to get a little clearer.

We have strong evidence that nicotine-containing vapes can negatively impact lung health. We don't have human data linked strongly to cancer, but some preclinical data suggests cellular changes predictive of cancer. There are impairments in lung health and the respiratory system, as well as negative cardiovascular impacts.

Paula Rodriguez-Miguelez, Ph.D., in the Department of Kinesiology and Health Sciences at the VCU College of Humanities and Sciences, did some exciting work looking at young people who vape, with little smoking history, which is important to truly understand the effects of these products. Her studies looked at lung and cardiovascular health and preclinical disease markers, things that wouldn't show up if you went to the doctor and they looked at your lungs and heart. She looked at the microvasculature, the small blood vessels, and saw impairments suggestive of later cardiovascular disease development, in comparison to people without a history of vaping or smoking.

Gum disease development is another area where we're starting to see impacts related to vaping. Gingivitis, tooth loss, and those kinds of outcomes certainly overlap with combusted tobacco products, but are not identical. They're very different aerosols, but certainly not harmless, so it's important that people understand that those products carry risk and some unknowns when it comes to long-term outcomes.

Can you speak to the difference between long-term smokers who vape to wean off cigarettes vs. younger folks who have never smoked but started with vaping?

There is a push and pull between having these products available on the market. About 39 vape products on the market have been authorized by the FDA, but if you go into any convenience store or vape shop, those are not the products that you'll see. You're going to see highly flavored, nicotine-delivering products that are geared toward kids or younger people.

For someone who smokes and has been trying to quit without success using FDA-approved methods, they might turn to a nicotine vape to help. I think that's a fair choice because they've exhausted all these other options, and there is strengthening evidence that nicotine vapes can help people quit smoking.

We've got a systematic review of studies across the world showing that, compared to nicotine patches, vapes even seem to be more effective. Again, it's not a huge effect, so this product isn’t going to help everybody, but for some people, it can.

If you're using vapes to quit smoking, ideally, you want to have a plan for getting off vapes as well. The challenge is in the marketplace. There's no way the FDA and state regulatory authorities can control the availability of these other products, including ELFBAR, RAZ Vapes, etc. Some of these products look like games, with integrated speakers and all these entertainment features. Those products shouldn't even be available for sale, but unfortunately, regulators cannot keep up with the marketplace.

Can you speak on tobacco pouches?

Tobacco pouches are fairly new, so these are different from your typical smokeless tobacco, which is basically shredded leaves. Sometimes they're manufactured in different forms, but newer products, like Zyn, are basically just nicotine with flavorings and other additives in a small, teabag-like pouch, which is placed in the mouth and is effective in delivering nicotine. They're interesting because it’s likely a safer way to consume nicotine if you use smokeless tobacco. You're not going to be exposed to a lot of the tobacco-specific carcinogens that come from the leaf, but it still carries the potential risk of nicotine dependence.

Nicotine is also a stimulant. It can affect the cardiovascular system, and for young people who have not been exposed to nicotine, those risks are important, as well as the potential for them to transition to other forms of tobacco in the future if they initiate with something like this.

We don't know a lot about these products. We've done a few studies here at VCU and with my research team to understand their effects in people who use smokeless tobacco. But the scary thing is the initiation we're seeing with younger people who did not have a history of tobacco use before. It’s similar to vapes, since there's this potential for harm reduction, but it carries risks of introducing a new generation to nicotine.

Are there any resources at Massey for people who want to quit smoking?

We have the We Can Quit program, a community-centered service Massey provides, with quit coaches, support and phone-based counseling.

We have free telephone counseling in Virginia and text-based support.  If you live in the city of Richmond, there are also specific cessation supports offered by the Department of Health.

Are there available cancer screenings for people who smoke?

Lung cancer screening is very important for people with a long-term smoking history. One of the reasons why lung cancer is so deadly is that it's often caught late. But we can combat that through lung cancer screening. The Early Detection Lung Cancer Screening Program at VCU Health provides that opportunity if you currently smoke or smoked in the past and are between the ages of 50 and 80. It really can save your life. Call 804-827-LUNG (5864) to schedule an appointment.

Smoking Cessation Resources

To learn more about smoking cessation resources available through Massey, the City of Richmond and the Commonwealth of Virginia, visit the website for further information.

Written by: Tatiana Del Valle