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EP10 The Tobacco Research Lab with Dr. David Abrams, Dr. Raymond Niaura and Mahathi Vojjala
Deborah Onakomaiya: Hey guys, welcome to another episode of I AM GPH. I'm your host, Deborah Onakomaiya. On the show today we have two faculty facilitators and a research coordinator from the Tobacco Research Lab at NYU. We are joined by Dr. Abrams, who is a Professor of Social and Behavioral Sciences here at GPH. He is also a faculty facilitator for the Tobacco Research Lab. His career focuses on system and social learning frameworks to inform population health enhancements. He is currently working on strengthening global and US tobacco-nicotine management strategies. We are also joined by Dr. Niaura, who is a Professor of Social and Behavioral Sciences here at NYU. He is a psychologist by training and an expert on tobacco dependence and treatment, as well as substance use and alcohol addiction. Just like Dr, Abrams, Dr. Niaura is a faculty facilitator at the Tobacco Research Lab. Finally on the show today, we are joined by Mahathi Vojjala, a junior research scientist and research coordinator at the lab. She's a 2017 alumni of GPH from the epidemiology track. During her two years at NYU, her research focused on smoking initiation and media advertising, and the dual use of marijuana and cigarettes among youth adults. Let's go to our conversation with them. Hey guys, thank you so much for coming on our show today. It's really nice having all of you here.
Mahathi Vojjala: Thank you.
Deborah Onakomaiya: Let's dive right in. Please tell us a little bit about the Tobacco Lab in terms of mission, vision. How did this lab all start?
Mahathi Vojjala: The lab started in 2015 by Dean Cheryl Healton. The main vision for the Tobacco Lab is to create a research community which is free of where we look into tobacco and nicotine addiction related to health issues and health outcomes, and to create a community that's tobacco free, essentially. We have 10 different faculty members involved with the lab and 18 students right now, so it's a pretty decent sized lab.
David Abrams: The lab is really part of a broader vision, which is about the impact of tobacco and nicotine on public health, and the fact that we're aware that if nothing more is done to reduce, particularly smoking among the world population, that a billion people will die prematurely by the year 2100, if we don't do more. The lab is actually part of a bigger picture to understand who uses tobacco, how they use it. We're particularly interested in these new products that are coming out and things like hookah use or electronic cigarette use, which has changed the picture quite a bit. All of that can be looked at within the lab because we have a very big data set that was collected by the Food and Drug Administration. We're giving all the students who come into the lab an opportunity to look at some of the data, ask questions, and maybe write papers that could ultimately even be published and make a difference in terms of saving lives.
Deborah Onakomaiya: That's important. Would you want to talk a little bit about what you're doing in the lab?
Raymond Niaura: Well, as David just mentioned, one of the very exciting things about this lab is that we can collect interested individuals and pool resources to tackle important problems. This dataset, it's called the path data set, really is a golden opportunity to do that. To both help students learn how to analyze data, but more importantly also how to interpret the data and then communicate back to the public about the findings, indicating not only where the problems lie in terms of tobacco product use, but also where the potential solutions lie.
Deborah Onakomaiya: That's really important. You've been talking a lot about data and analysis, but I think for me I'm more interested in where is this data coming from? Is it coming purely from New York City? Is it all around the world? The data that you guys work with at the Tobacco Lab.
Raymond Niaura: The study that we're working on, primarily the path study, that is a study of the US population. It's not worldwide. Just to get a little technical about it, it's a population based study, which basically means it's a random sample of the US population and it's split into two pieces or components. One is there's an adult sample and that's about 40,000 individuals. And then there's a youth sample, 12 to 18 years of age, and that's about 12,000 individuals. What's almost unique about this study is it's longitudinal in nature, meaning that we're following people over time, which is incredibly important. Most surveys are just a snapshot of what's happening at any given point in time. The other piece that's a little bit unique is that this is a household survey. We have the opportunity to look at tobacco use within households, which also means within families. We can look at important things like, how do families influence whether kids or other people use tobacco products or not? There's a richness of data that's available. But I do want to mention that we're not exclusively focused on the path study, we are very much interested in global tobacco use and working with other types of data that might become available to us.
Deborah Onakomaiya: What do you look for in people that want to be part of the Tobacco Lab?
Mahathi Vojjala: The students actually serve three different roles. We have research assistants, research lab managers, and student serving communication roles to watch over the Facebook page, to work with that and our other communications social media website. In regards to what we're looking for for students, we're looking for students who have an interest in this type of research but also with some data analysis skills. We also have students in the lab that don't have the background in the data analysis aspect of research but are working with the other faculty members that are involved with the lab or at the medical school and these students work with data collection, recruitment, coding, qualitative coding, quantitative coding. In that sense they get a broad range and exposure to a research study. In what we're looking for students is mostly students with data analysis skills to work on the path dataset, but then also other students who are interested in this type of research.
Deborah Onakomaiya: That's really interesting because I know a lot of our listeners have heard about the Tobacco Lab but are not sure. Are the only epi students allowed? Or only biostats students?
Mahathi Vojjala: Everyone.
Deborah Onakomaiya: Everyone's welcome. That's really awesome.
Raymond Niaura: We're interested in people who are curious, committed, and dedicated to, and like to learn how to work in teams, and like intellectual challenges that have public health significance.
David Abrams: Yeah. Just to add to that, I think we're very interested in all the different skills that could be enriched by an experience in the lab that have to do with how a practitioner might learn how to take what they understand and turn it into policy or working in a department of health. It's a series of skills that doesn't just focus on data, or epidemiology or biostatistics, although that's part of it. As Mahathi was saying, we also have people at the med school who are doing actually interventions with patients or communities. Those that are more interested in health policy and management or socio/behavioral science, can work with folks on actual interventional treatment studies, all of which go into how science is done and how to understand how science informs policy making to make a whole community, or a whole society, more healthy. There's a lot of different experiences that people can get in the lab. But one of the causes is how science can inform policy.
Deborah Onakomaiya: You touched a little bit on some of the past research, or current research, that's going on. Could you just tell us maybe one or two things that might've come out of the lab from students, or from research projects that you did, some past successful research that might have come out from the lab?
Mahathi Vojjala: In the past, we had faculty from the medical school and from CGPH in the past and this year. We had students working with dental students through the med school. CGPH, MPH students working with dental students to know their research topic was knowledge and prevalence of hookah use and detrimental effects of hookah. They were primarily working with a professor called Dr. Michael Weitzman, and that was a successful paper that came out of it. So they were actually in Italy presenting at a conference over the summer last year. That's one of the successful papers. Other successful papers are people worked with Dr. Cheryl Healton and another NYU adjunct faculty, Dr. Donna Vallone, and working on different datasets and analyzing different datasets. I feel like there were quite a few successful projects in that sense.
David Abrams: Just to add to that, students are working also with several other medical school faculty, like Dr. Scott Sherman, Donna Shelley. Who are doing treatment studies with people like VA patients or recruiting people from the community to understand why they're struggling with smoking, how to quit, and to do interventions to help them quit. Some publications have come out of that as well. As well as working with the Department of Health and other universities here, like CUNY, on surveys that have been done of the local communities, so we understand what's going on in New York City and some particular interests are in low income and high income neighborhoods and how tobacco products are sold at point of sales. Dr. Tom Kushner is doing work with cell phones and tracking systems with geospatial coding so we can link where people are with local stores, and understand how marketing and sales get delivered at the point of sale. Those projects are underway. They've involved students and several papers as well as understanding of how all of this leads to make it hard for people to quit and how marketing gets used to get people to use these products it is done specifically in New York.
Deborah Onakomaiya: I honestly have to ask, what inspires all of you to be so involved in this particular line of work? What's the back story? Why are you involved so much in tobacco research and things like that?
Raymond Niaura: Well, for me it has to do with my background in health psychology and behavioral medicine. Actually in my early days, and David as well, we worked in a hospital setting and we would have to deal every day with the consequences of tobacco related illnesses. Once you see that up close it sticks with you and then when you move to more of a public health perspective, it becomes pretty obvious that one of the most important things we could do for the public globally is address the issue of tobacco use and tobacco related disease. We got hooked early and passionately, and we just continue doing as much as we can.
David Abrams: For me, similar, but also I come from South Africa and as an early childhood, both my parents smoked. My dad and my mom. I happened to be, as a young kid, I just got interested in trying to get them to quit and I don't really know why. But my dad quit when I was about 13 or 14, but he still died of a heart attack when he was quite young. I think some of it was exacerbated by cigarette smoking and pipe smoking. So I got very passionate because of a personal experience in my childhood. But also coming from South Africa I don't like the idea of people becoming victims, or people who are taken advantage of, and then struggle for the rest of their lives with something that could kill them. In fact, half the people who smoke die prematurely of their smoking related diseases. I'm just very passionate about social justice, trying to improve people's lives, especially for things that are completely preventable.
Mahathi Vojjala: Similarly, I come from India and the prevalence of smokeless tobacco in India is so high that it's a huge problem. But I think I was exposed to tobacco research from a more marketing and advertising aspect. The exposure to portrayal of tobacco in movies and TV shows, especially in the United States and abroad, and with no regulations abroad in most countries. Again, with Indian movies, the exposure, the way they portray tobacco and alcohol use, it's really ridiculous. And it's really sad because they have kids watching these movies and they think it's cool, or they think that that's something that you should do, that's romantic, that's cool. So, I think I was exposed to it from that aspect and I wanted to learn more about tobacco research. It was awesome because I was working with people from the Truth Initiative and with our Dean, so it was a different aspect but also very passionate about social justice. I think it's a huge problem that we still need to combat. People still think that we've done everything for tobacco research, tobacco smoking rates have gone, cigarette smoking rates have gone down, but they're still a lot more work to do.
Deborah Onakomaiya: I think I'm sure our listeners, especially those who are in the public health field is like, the data is out there, the statistics are out there, yet people smoke. In your opinion, why? Why, even in the face of undeniable evidence that there's no benefit to smoking, why do you think people continue to do so?
Raymond Niaura: A big part of it has to do with the fact that cigarettes in particular are highly addictive products and people essentially lose control of their behavior to varying degrees. They have to sustain their addiction by smoking. It's difficult. Part of the definition of addiction is that you keep doing it even though you know it's not good for you, or you're suffering from tobacco related illness. That's the big challenge. How do we address that both at a personal level, at a societal level? What are the tools that we need to develop to help people break through the addiction, to quit, or if they can't quit, to switch to behaviors that are less harmful. Those are the challenges and those are the things that we're interested in looking at.
David Abrams: Yeah. Just to expand on that, I think also some people will smoke because nicotine actually makes them feel better. The nicotine might help their brains to function a little better because we know from neuroscience that nicotine can improve concentration and memory, and therefore certain people, a lot of kids will try cigarettes, but only 20 or 30% will go on to a lifetime of addiction. We wonder if some of that doesn't come with the fact that the nicotine's helping them in some way. It's particularly interesting that people with mental illness or substance abuse problems are very high smokers. The problem is that when you deliver nicotine by burning the tobacco in any combusted product, and that means cigarettes, little cigars, hookah, pipe, or roll your own, in other words, burning the tobacco, you can't separate the nicotine, which might be of having some benefits, although it's still a drug and preferably no one should use it. But you can't separate the nicotine from the 7,000 toxic chemicals in the burning of the organic tobacco material. What kills people is the tar, the toxins, and the carbon monoxide that they inhale in order to get their nicotine. The whole idea of harm reduction is nicotine replacement therapy is supposed to give you the nicotine, which you still may want, but decouple it from the burning of the toxins in the tobacco smoke. Now we have all these new products, like electronic cigarettes, that I think are a breakthrough technology where you might actually be able to give smokers the nicotine they want, or need, in a fairly satisfying way that can compete with a cigarette, but without all of the toxins and harm because it has no tobacco in an e-cigarette, it's nicotine in an aerosol delivery called a vapor. We're now on the threshold of a different form of harm reduction that's quite controversial, but some people think that any smoker who's currently using cigarettes, or cigars, or any form of burning tobacco to inhale the lethal smoke, if they can't stop, they should switch to a less harmful product. Either an e-cigarette, or an FDA approved nicotine replacement therapy, like the patch, or the nicotine gum, or a lozenge that are all readily available. It depends if you believe in harm reduction, that if somebody can't stop completely, you'd rather have them using a much less harmful product, as opposed to saying you shouldn't touch any of this. But certainly kids, we want to discourage anybody under 21 from using any form of nicotine because it's not good for you and you can't eliminate all the risks. But for those who are smoking, or using nicotine, or want nicotine, I don't think you can condone prohibition of nicotine because it doesn't work. People will get it anyway. It's been around for 5,000 years. Prohibition of alcohol didn't work and we've now got all the issues around marijuana use. So it's raising some really big public health questions about the world is changing. How do we retool public health strategies? Underneath all of this is a very challenging question for public health on what would the new policies be, given that the whole world's changing and all these new things are coming? So we're actually both excited and anxious about how we should thread this needle to do the most public health good and minimize the damage. Protect kids, but help smokers who can't stop to go off the cigarette, or the smoked tobacco, and use something else if they can't stop. I'm a proponent of harm reduction where I think I'd rather have someone who's smoking cigarettes switch and still enjoy, or get their nicotine, in a different way if they can't quit, than tell them they should stop everything.
Deborah Onakomaiya: What school of thought are you?
Raymond Niaura: Well I think what David said is certainly a real possibility. But to circle back to the path study, that study actually enables us to examine some of these very questions. Because the study is tracking things like use of other alternative nicotine delivery products, we actually can look at people who switched to these products and hopefully be able to look at their health outcomes. We can then be able to determine whether their health outcomes are improved if they switched to these less harmful products. These are the types of questions that I think are becoming more important. But now in the Tobacco Lab there's an opportunity to actually look at these things.
Deborah Onakomaiya: Yeah, definitely. I think my final question is, is the future bleak or bright in terms of tobacco usage? Because you hinted a little bit about burnout, they've done everything, we've reached a point of all these interventions. Is the future bright for tobacco research? Should we be hopeful?
Raymond Niaura: Absolutely, we should be hopeful. Just as the College of Global Public Health is reinventing the public health paradigm, we need to reinvent the tobacco paradigm. That's part of what we're striving to do. We're trying to do it in a science and data based way. That's part of the mission is we really need the facts. We need the evidence. We need the cool heads to evaluate the evidence and point the way forward.
David Abrams: Yeah, I agree with that. I would add, I think there's always hope and I think we can definitely do better than we're doing now. But not in 120 years that we had this extra ordinary crossroads opportunity because of the new technology to reinvent tobacco control and do even more good, much more rapidly than any of us ever thought possible just 10 years ago, before the invention of the e-cigarette. While that's controversial and there's some traps and concerns about these new products, I'm very optimistic that we can actually use them to much more rapidly eliminate the dangers from smoked tobacco much more rapidly than we ever thought possible even 10 years ago. We're at the right place at the right time to make a huge difference. I don't think we should squander the opportunity, but we should be very careful that we use science informed data with rapid feedback on how big things are changing so that we can thread the needle and do more good than we've ever done before.
Mahathi Vojjala: Yeah, I definitely agree with both of them. I think we have tried a lot of interventions and a lot of implementation of these interventions, but there's still so much more to do and if, especially across the world globally, also with the rise of alternative tobacco products and the rise of smokeless tobacco in different countries, I think there are many aspects of regulations and policy work that we can really work on from a science perspective.
Deborah Onakomaiya: Thank you so much for being on our show today.
Raymond Niaura: Thank you.
Mahathi Vojjala: Thank you.
David Abrams: You're welcome.