This webinar was recorded on October 5, 2023 

Around 61.6 million individuals in t he ​United States currently engage in the use of ​tobacco or vaping products containing ​nicotine. Moreover, within the past 30 days, approximately 23.6 million people have developed dependence on nicotine. Exposure to secondhand and thirdhand smoke poses notable health risks to the general public. To address this issue, ​Dr. Fino will be conducting a ​webinar that focuses on imparting effective techniques for teaching tobacco cessation to communities with limited resources. This webinar will also explore and analyze the various methods patients employ, such as nicotine replacement and nicotine substitutions, for managing their nicotine consumption.


  • Jessica Fino, EdD, RRT
    Midwestern State University

Dr. Jessica Fino is an Assistant Professor of Respiratory Care at Midwestern State University in Wichita Falls, Texas. She earned her Doctor of Education for Health Professions from A.T. Still University.  As a respiratory therapist, she has experience in adult critical care and neonatal and pediatric care. Dr. Fino is a Freedom from Smoking Facilitator through the American Lung Association.

CE is not available for this webinar.

Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

De De Gardner: Hello everyone. My name is De De Gardner and I am the Chief Research Officer for the Allergy & Asthma Network. I want to welcome everyone to this afternoon’s webinar. We are extremely fortunate to have a real treat with Dr. Jessica Fino as our presenter.

We have a few housekeeping items before we start today. First, all participants will be on mute. We will record today’s webinar and post it on our website in a few days. You can find all our recorded webinars on our website. Scroll to the bottom of the page to find our recorded webinars and upcoming webinars. This webinar will be one hour and that includes time for questions. We will take questions at the end of the webinar, but you can put your questions in the Q&A box at any time. The question-and-answer box is at the bottom of your screen. We have someone monitoring the chat if you have questions or if you need any help. We will get to as many questions as we can before we conclude today’s webinar.

We will not be offering continuing education credits for this webinar, but we do have a certificate of attendance available if you need it for your records. A few days after the webinar you will receive an email with supplemental information and a way to download the certificate of attendance. We will try to add a link to that certificate in the chat.

So, let’s get started. Today’s topic is real-world tobacco cessation strategies in under resourced communities. Around 61.6 million individuals in the United States currently engage in the use of tobacco or vaping products containing nicotine. Approximately 23.6 meeting people have developed dependence on nicotine. Exposure to secondhand and thirdhand smoke poses notable risks to the general public. Today Dr. Fino will discuss effective techniques for teaching tobacco cessation to communities with limited resources. This webinar will also explore and analyze various methods patients can employ methods such as nicotine replacement and nicotine substitution for managing it.

It is my pleasure to introduce Dr. Jessica Fino who is an assistant professor of respiratory care at Midwestern State University in Wichita Falls, Texas. She earned her Doctor of Education for health professions. As a respiratory therapist, she is experienced in adult critical care and pediatric care. Thank you for being here today, Dr. Fino. I will turn it over to you.

Dr. Jessica Fino: Hello everyone. It’s a pleasure to be with you today. A little bit about me as I have been a respiratory therapist for 14, almost 15 years. Like De De said, I am a facilitator for Freedom From Smoking from the American Lung Association. Besides my smoking cessation education, I have been an advocate for teaching this topic for about the last four or five years. I started with the fresh start program through the American Cancer Society. They have evolved their content a little bit and so I have crossed over to the American Lung Association with their Freedom From Smoking program. I am very excited to help present this topic and help the Allergy and Asthma Network meet this portion of their mission.

A little bit about me is, you will hear me reference the program that I have talked about, and I wanted to give a bit of background information about my program so that you can have a better understanding of why this topic is near and dear to my heart. I am an assistant professor at Midwestern State University. I recently took over our rehab’s health promotion course. I knew I wanted to start a project with my students where they were allowed to teach smoking cessation. Initially I started with our local health department. More or less, we witnessed and watched them teach their program and we got to be listeners on that topic. And then as COVID happened in the last few years. So, I immediately identified the need in our community for smoking cessation and that is when I took on the program myself and became a Freedom From Smoking facilitator and started offering classes to the University here and allowed my students to teach alongside me.

That was great, but then I also found that when offering classes to the general public, often times they were somewhat unreliable in showing up, really ensuring that I had a great attendance as far as participants. So I transferred to a transitional housing unit in my community known as sober living in Wichita Falls. And we teach smoking cessation to individuals who are recovering from addiction. Oftentimes it would be illegal substances in their addiction history and so they have fulfilled that requirement of their program. But smoking is often, in today’s society, kind of the acceptable addiction. So that’s is where I wanted to come in and share the norms that may be acceptable by society, because it is not illegal. But that is where I wanted to jump in and offer this program to these individuals.

So that is my background on that. Again, you will hear me reference the American lung Association often in my program because that is my own experience. I am not aiming to unnecessarily highlight any particular product or service.

These are my objectives. I want to describe the different approaches to providing tobacco cessation. Often times particularly targeting those under resourced communities. Because personally, I believe that not all smokers are the same and not all have access to the same resources and programs. I believe the message should be the same, but the approach to teaching it to every group shouldn’t be the same cookie-cutter approach. I also want to identify the obstacles and common misconceptions associated with helping individuals in their journey to quit nicotine. Because each group, whether it be the homeless or transitional-type population whether it be youth at the clinic or the general public, each group will present with their own set of obstacles. Being prepared for the different obstacles in different communities can sometimes produce a better program and help participants meet their goals. Lastly, I want to recognize the role that we all have in spreading the hazards of smoking and also tying in a bit of information about vaping.

I believe — personally, my message is that it should be more than just smoking is bad for you, don’t do it. I have found over the years that individuals that I work with, they know that it is bad for them. It is just that quitting is so hard that that is where they really struggle. And so this is how I will break it all down for us today.

I want to look at this information from the perspective of who we are wanting to teach, how are we going to develop a strategy, and then how will be executed and put it into action? When we look at who our audience is or who we want to teach, smoking is the leading cause of preventable death in the United States. On average, about 480,000 deaths occur each year due to smoking related illnesses. To put that into perspective in preparing for this is, I started looking up populations between 475,000 and 500,000 individuals. For example, that would be Colorado Springs, Colorado. Or the entire population of Atlanta, Georgia. If we lost the entire city every year, that would be approximately how many people died from smoking related illnesses each year.

So, when we start looking at our target audience, you have quite a number to draw from. Smoking is directly related to about $50 billion in the total economic burden. And about $30 billion of that is directly related to health care expenditures. So I don’t know about you guys, but I can think from my experience of working in hospitals, there are a lot of places I would like to spend additional $30 billion. On top of that, the average person who is a smoker can spend around $6,500 a year on medications, doctors’ visits, co-pays and durable medical equipment.

I think that is important whenever you start looking at these under resourced communities, because you realize that a lot of times, funding for the programs is for the participants themselves, is not a commodity. We have to look at additional areas to gain funding. And I think addressing those components with the participants makes them a little more relatable because they don’t understand how much money they are spending on their tobacco products.

So, look at finding your audience within your community. Here is the latest information from the American Lung Association broken down by ethnic group. When we look at the demographics, we often want to look at who our smokers are. Over the last decade, we have seen that the total number of smokers have declined. However, it is still a major contributor to the cost on the health care system, and it is still the number one preventable disease. So typically, there are more men that are smokers in the United States, more than there are women. In the last two clinics I have conducted in the last couple of years, I have had between 15 and 20 participants in each clinic. I have only had two of them out of 50 people, only two of them that admitted to picking up the habit of smoking after the age of 18. I think it very much correlates to trends that a lot of time individuals who are long-term smokers pick it up at the age of adolescents.

That is really important to consider when you consider recruiting in schools or looking at youth. A lot of statistics currently support that a lot of individuals took it up in their middle school years. So that is another area that helps us identify where our true audience is. I also like to identify interests within the community. Are there any commonalities among your target audience? For example, if you are wanting to look at schools or youth, if you’re looking at afterschool programs or schools, are they primarily athletes? Could we recruit based on the health benefits and the performance benefits if they would quit smoking?

If you are potentially looking at rehab clinics and things like that, I found a lot of times when working with physicians’ offices and pulmonary rehab clinics, it is the logistics of getting the patients there. Would it be possible to offer the classes at a time before the program or appointment starts, or shortly after their appointment and, could we get them scheduled on the same day? Different ways we could tailor their appointment to cater not only to their specific interests but encourage them to attend. Often times with smoking cessation classes, getting them there and getting them to attend is often times half of the battle. And sometimes depending on which community you are looking at, it may be two-thirds of the battle, just getting them to attend and show up and be there.

You also have to consider that whenever we look at tobacco and nicotine, the big tobacco refers to it as the tobacco industry altogether, they are very, very good at what they do. They’re very, very good at advertising to these different communities, somewhat disproportionately. They target, a lot of times, the low income and at-risk communities for their products. I feel like we have a greater appearance of ads, redundantly, say in our African American communities where we may see larger advertisement near homeless shelters, or that type of environment where they support the LGBTQ+ community, where sometimes the commercials or the ads on the billboard signs and things have marketing that appeals to those communities. If they are that creative in marketing their product, we have to combat that somewhat with our creativity and marketing of smoking cessation programs, because if they will be good at what they do, we will have to be good at what we do.

When I look at developing a strategy or how I will approach teaching a class, how I will find participants, what content I will teach, I break it down by different programs. Again, I know that there are different programs out there. Some of them are tailored to be shorter, I know that is not necessarily a downside of the Freedom From Smoking through the American Lung Association, but it is one of the longer programs. It is designed to be over seven weeks and it is a total of eight classes. I enjoy that format because it allows you to develop a relationship with the participants and I feel like they really trust you by the time you are done teaching the classes. But I understand also that logistically, that can be a somewhat unreasonable request from participants. Some of the smaller classes are about four weeks where you meet twice a week for two weeks. I know that the CDC and the American Cancer Society have programs and content that are tailored by individual lessons, so you would have more flexibility on how you would present that information depending on who your audience was.

Another thing to look at is the program requirements. They can help you kind of decide on which program you want to teach or look at. It also helps you with keeping up with the materials and ensuring that you have participants who will actually show up and come. Looking at resources, sometimes you have to find funding to support your resources and vice versa. So I know that with the Freedom From Smoking program and with the Fresh Start program, you have to have books. It was a requirement of the program that each participant receive a book. With the American Lung Association, the books were about nine dollars each, that is what it cost me to purchase them. That is something that depending on how your program is set up or what type of funding and resources you have available, may be a big deal. For some, we have no funding to allocate to this or very limited funding. Nine dollars per participant may be an overwhelming cost. Those are things to consider when you’re trying to decide what content you want to present.

And then looking at the support within the organization, is it just you? Do you have a team of people that can help you? When I first took this on, I used my students to help me somewhat, but also, I feel like in order to develop a successful program, you will need additional support because we have to call these participants and remind them where we are meeting. We have to get them registered. There is sometimes paperwork and surveys and sometimes they have to be explained on the one-on-one basis. So, there is a bit of paperwork and things along those lines that I take over in a secretarial standpoint that often times when you have support, those kinds of things can come up and that would be a reason why you could go with one program versus another.

Funding is a big one. How are we going to make this happen? So, before I get too much into funding, I want to talk a bit about how we would maybe get into those communities, if you don’t already have an in with the community you are trying to reach. Potentially partnering with existing programs. Like I said, when I first got into this, I partnered with our local health department, and I said are you teaching this topic anywhere? Is there any initiative could potentially join in with you? That is where I got initially partnered with our local health department. Unfortunately, when COVID hit, everything was at its peak, they were at the time for their tobacco cessation grant and all of the funds were allocated towards COVID relief, which was understandable. But it left me at an impasse where I was like I don’t have necessarily a foundation anymore. That was when I started looking at what options were out there and decided to take this upon myself.

I don’t know if there are any schools or universities or any type of health system where you are located where you could potentially partnering with it as well. I feel like almost any respiratory school would entertain the concept of helping in this endeavor. But I also know that our nursing program, I partnered with our university, also helps with the awareness of tobacco. If you are looking at afterschool programs, or maybe schools, I know that a lot of times, getting partnered with the student special interests, whether it be sports or athletic directors or band directors, like, the students already had to be at a practice. Is there a time I can spend 20 or 30 minutes talking to them? Maybe just a few minutes a week? Sometimes with that age group, repetitive, small repetitive measures are how you can get in with them.

And with the recovery center that I became associated with, the organization that I deal with, they have partnered with many different clinics within our organization. Specifically with transitional housing group. But they are also associated with the homeless shelter and the addiction recovery organization here in my community as well. So, with the addiction recovery, that has become very successful because what we have identified is that there is actually a class that they go to each week. How they get them in the door is they offer them food. They offer it once a week. They feed them and these individuals, they break them up into different topics that they will go and have a class on each week. So sometimes it is parenting skills. Sometimes the topics are job placement and job skills because a lot of these people do have a criminal history. Sometimes it is difficult for them to overcome and find appropriate job placement.

So they have decided that next year, they will add me and my program as an additional topic on Celebrate Recovery nights. I will get to meet with these individuals and talk about smoking cessation. This wasn’t something I was necessarily aware of, but I just kept asking, how can I help? How can I reach your participants and your individuals within your organization? So, word has kind of spread.

You may also look at potentially different pulmonary clinics or different health care facilities and see if they are offering any type of tobacco cessation programs. Is there a way that you can get in and assist with either ongoing efforts o you could start something up with their patients.

With this, often times I have found that I had to seek some outside funding. Funding was not generally available within any of these organizations or potential community members that I mentioned. And so, especially in the under resourced communities, often times funding is, I feel like, stretched thin. So there are a few funding ideas that I came up with here that grants are probably the most profitable because you can get larger amounts of money at once. But I do know that grants oftentimes require a lot of planning and a lot of effort from the individual themselves. And so — I know I recently applied for a grant, and it took several months to get the information together. So just a few ideas of different grants out there that are tailored to work this topic, community service grants. There is a community service grant with the American College of Chest Physicians. They do that once a year. The CDC also has some tobacco control programs. There is also an organization known as the Substance Abuse and Mental Health Services Administration, SAMHSA. They have a national Center for Excellence for Tobacco Free Recovery specifically looking at individuals who have had a substance abuse history or a mental health history. So, there are lots of potential options out there relating to grants that I feel like this topic could potentially relate to.

But I understand that grants take time and effort. Sometimes you have to get a lot of parts and pieces together in order for that to occur. So, if you are in a time crunch or you want to see some of this being implemented quicker, you might seek funding from independent organizations. For example, this may be for-profit health care agencies or donations from hospitals or clinics that potentially have the funding to offer classes, but they are needing to partner with someone to actually carry out the classes. So initially this is what I did for my first class, I reached out to a local for-profit concierge medical service. I knew that this organization had this type of programming. They didn’t offer it, but they offered community service-type assistance for our local communities. They had made that type of presence known in our community. My initial award was $500. Five hundred dollars is not a lot in today’s society. It allowed me to get the books that I needed. And it allowed me to provide tobacco — nicotine replacement therapy for our participants for up to four weeks following their course. And it allowed me to provide small incentives to keep them coming to the classes. So just depending on where you are and the cost of things, you don’t necessarily have to have an astronomical amount of money to get things started. I knew that I had a small amount, so I limited my class to 15 participants. So, just depending on what you are looking at, there is definitely options out there.

For my upcoming classes, I am looking at specific ongoing donations, looking at donor funding type approach with this. I have emailed local community members, individuals who I know have been affected by lung cancer and smoking related illnesses. Oftentimes you can get those in memoriam-type donations in any amount. We have also done campaigns on social media where my students helped me create commercial-like REELS that spread the awareness of tobacco cessation. After that was over, they created a code that said if you would like to support our efforts, you can donate to our cause.

There are also special events. These special events don’t necessarily have to be like donor dinners or fancy sit-down type dinners. The event I have done with my students is the Great American Smokeout, it is a campaign that is advertised through the American Cancer Society. It happens on the third November of every year — sorry, third Thursday in November. So, whenever that happens, they encourage individuals to stop smoking cold turkey for 24 hours as the kickstart for being tobacco free.  What my students did, we dressed in funny costumes and walked around the common areas in our community, and they got attention because they were holding up signs that said they were dressed like Christmas trees and elves. It was, like, give your family the gift of you this holiday season. They were dressed like clowns and had a birthday cake and said, celebrate more birthdays. They were dressed in dinosaur costumes that said “don’t go extinct. Give your family more time with you.” Different things like that. And we obviously had a large cigarette costume in which we were able to share our true message which was to stop smoking. Individuals were stopping like crazy to donate to our cause as far as that goes. It doesn’t have to be a big, elaborate dinner to generate some level of funding. Like I said, $500 was all it took. I didn’t take the full $500 to get the program started from the very first time.

OK, so how will we put this into action and make it happen? So, from the perspective of teaching the content, people have to have commitment. Because I found that under resourced communities sometimes make it more difficult to hold the classes because the students may struggle with transportation issues, with legal concerns that prevent them from being free to come to the classes. Sometimes they have personal struggles outside of the content covered in the classroom. They may have personal issues going on. We also found that with addiction relapse is sometimes something that occurs within that particular community I was working with.

So sometimes it is easy to become discouraged, or even frustrated with the process. But I feel like it is important to take the perspective that we should expect frustration. Frustration from the participants, frustration on our end, but you have to have endurance to keep going. The latest statistics show that most smokers require 8-11 attempts before quitting for good. So I do know about you, but approaching anything that took me 8-11 times, I probably would have given up before then, if I am honest. So just having that assurance to keep offering the classes, to keep reaching out to the participants, to keep showing up with enthusiasm, to remain engaged in the content and remain engaged in their participation, is a key piece to having a successful tobacco cessation program.

I would like to tell my participants that even though they may miss a meeting or two meetings, I will still reach out to them and stay in contact with them. If they are willing to make the effort, I will try to catch them up on the content. I had one participant in the past that after our quit date, we had a celebration midway through the program, and she got some very upsetting personal news. And she smoked that day. She was afraid to come back to the program because she was afraid that I would be so upset with her. I had to reinforce the concept that that’s not what I would have liked for you to have done, but that doesn’t make you a failure in this process. So that has a lot to do with accountability. The Freedom From Smoking program actually requires that all facilitators be smoke-free. Often times we have to model the behavior we are expecting. I feel like in that instance where she admitted to me that she had a small relapse, don’t approach those individuals from a perspective that is harsh and judgmental. Because this is a process. Quitting tobacco is, it is an addiction. It is something that has been learned and something that will take time to break.

I want to reinforce the concept of setting goals that are achievable and goals that we can accomplish together as well as independently. That has a lot of follow-through. If they hold up their agreements, agreeing to change their behaviors and through the process of the program wean off of their nicotine products, I have to call them. I have to show up when I said that I will show up. If you have the funding to follow up with these participants after your content delivery program has ended, the better.

I reached out to a couple of my participants over the last week. One of them was a three-pack per day smoker. Three packs per day. I triple checked that information to make sure. And he told me this last week that he has still not quit, but he is down to half a pack a day. So, in three months, we have gone from three packs to half a pack. In my view, that is a win. Here I am getting so much closer to him. He immediately responded to my messages and said, “I was thinking about you too, I can’t wait to be completely smoke-free. If I get a chance, I want to see you again.” So, instances like that where you build that community and trust with your participants, it really makes for a successful program and the participants will become successful recruiters for you.

Thinking about the topic and what you actually teach when teaching tobacco cessation, I think there are a lot of misconceptions out there. Not that any of these statements are untrue, but I just wanted to shed some light based on my personal experience of teaching these classes and highlight these misconceptions. A lot of times, individuals will feel like smokers in under resourced communities are uneducated. Statistics will support that statement. According to the CDC, more smokers have their GED than they do high school diplomas. There is definitely a connection where they are not necessarily the highest of educated individuals. But what I have found is that just because they don’t have the diploma or college experience or anything along those lines, it does not mean they are ignorant or uneducated about tobacco cessation.

Looking at my experience with these individuals, what I’ve found is they treated me like a fact checker. I almost couldn’t get to all of their questions. So, I introduced the concept of, tell me what you know about tobacco cessation. Tell me what you know are the risks. They literally wanted to know what popcorn lung was. Why vaping wasn’t better. How it was affecting their lungs. They were giving me specific examples of how they were breathing and what medications they were taking. A lot of information — I can’t explain how they work spewing information at me and I was instantly in that moment the truth-checker. Is this true? So, if you think about it, even in these communities, even the youth have those smart devices in their hands a lot of times. They can find the information out there. At this point I was more of, what can you trust and who could you trust?

So, it is important to present these individuals with information beyond, smoking is bad, here is a list of why it is bad for you and was bad for your health and here are all the things in your health that are going to go wrong. When looking at that, health risks should be the very focus of cessation. I do believe that, yes, there is a lot of information that can be shared relating to the health risks. But also whenever you look at quitting tobacco, nicotine is an addiction and so it is also important to consider the mental health and the social well-being of your participants and how when they go on their quick journey, how their mental health and social health will also be affected. A lot of individuals, I feel like, believe that vaping is a safer form of nicotine use and that is simply not true. There are different risks associated with it and I will talk about those in a second. Also, the fourth fact that I found when teaching these individuals, is, they really have no understanding of what thirdhand smoke was. They had a good understanding of what secondhand smoke was. But they believe that just because they weren’t outdoors or they removed themselves from their family members, that was all they had to do, that there was no greater risk because they were only exposing themselves to the byproducts of smoking. They believed that was all that was required.

So, these are important topics that I think every program should hit on. And I incorporated a few hands-on type of activities in teaching the content. Because I feel like this format of delivery of, “I’ll tell you about all these things that are bad and let me tell you about all the reasons why you should quit and here is the process by which you should quit,” these hands-on activities are what really hit home with these individuals, and this applies to almost every community. There is an example of where I had swine, pig lungs. Healthy lungs compared to unhealthy lungs. They kept asking me to bring them back out. They wanted to see them again and take pictures. They wanted to talk and show their family members these pictures. This is a particular activity that was extremely popular because they almost couldn’t believe it in front of their own eyes. And I understand that there are potential animal-rights activists that may not appreciate this particular activity, but I have a few others. This particular set of lungs runs about $450. But you can use them for a long time if you take good care of them.

Also, in covering the topics related to long-term birthweights and pregnant individuals who smoke, I have a premature mannequin, which looked like a baby doll that is extremely small. Suggest bringing that out to them, that was a real eye-opener. Because I think a lot of people can relate to premature infants, nobody wants to have one of those, but actually holding one in front of them and letting them see a lifelike individual that looks about the size of their entire hand, that was an extremely eye-opening experience for them. I even had a participant after the program who came and told me that she was expecting and that she was pregnant and she was afraid to tell me because initially, her experience in previous tobacco cessation topics, she felt very judged. And so, this was an opportunity for me to elaborate and explain that that wasn’t what I meant by this. That I would really like to become that messenger for you. I have several examples of different activities that I can share.

Barriers to quitting. There are significant mental health concerns. Tobacco use is much higher in individuals with known mental disorders. That a lot of youth report that they are also substance abusers beyond just tobacco users. Individuals with PTSD are a lot more likely to be smokers, as well as individuals who suffer from clinical depression. So, looking at the mental health side effects and the mental health concerns, it is important to be very upfront with these individuals, because whenever you go to quit, there are a lot of mental and emotional concerns that can come along with it. Such as these listed here. Many smokers have a history of depression. Nearly 20% have been admitted for having feelings of severe psychological distress. So it is important that when you go to treat, and that is why I like the group-type settings, because you develop a buddy system. They can help you have someone to turn to when you have moments where you are struggling. There are chat groups of smokers. You can find them here in this link that goes to the nicotine support groups.

Another important aspect, this wasn’t something I was initially prepared for, was the social loss. When you look at breaking the chain of addiction, you have the physical components, their withdrawal symptoms. We talked about mental barriers, but there are also social barriers. A lot of times smokers, whether it be vaping or tobacco use, it is a social aspect where “I have my coworkers I smoke with. My family members that I smoke with. I have my close friends that I smoke with.” So, one of the strategies to quit is to avoid those triggers. Avoid those individuals. Especially in these under resourced-type communities, their question to me was, what else can I do? Because they felt like they were having to give up their friends, having to give up time spent with their coworkers. They were at a loss of what to do with their time and who to turn to. They felt like they had in many ways lost their entire support system. There are particular models that sober people hang out with sober people. They felt like non-smokers should hang out with non-smokers. In the beginning, that is true, that is the best strategy for helping individuals quit. I felt like what are the best strategies to identify free or low-cost gatherings in your area, so one night I took them to the park, and we had our meeting at the park. We played basketball and just did things that they were not necessarily aware of that our community had to offer.

I also incentivized their participation for coming to the program. That if they came to every program or every meeting and they missed no meetings, I would put them in for a drawing for a gift card to a local restaurant. That was something that they weren’t regularly accustomed to. So that was also an incentive for them to keep coming. And then I think it’s also important to just reinforce their why. Their goals. Goals are very different when looking at under resourced communities. I have talked with some people where they said their goal was anywhere from, “My wife said I could buy a boat if I quit smoking.” But in under resourced communities, it is very different. For example, I heard someone who wanted to save money to be able to take their family out to dinner. They wanted to take their family out to a restaurant. So, you can see where the goals differ. They wanted to be able to afford and sit-down dinner. So just make sure you reinforce and identify their why and reinforce that goal.

With vaping, we have some special considerations with vaping, especially if you’re looking at the youth and their ability to somewhat hide the electronic cigarette. We have a whole different set of concerns on our hands, in the sense that it is still nicotine, we are still delivering nicotine in a device. But these devices, these electronic cigarettes allowed them to manipulate the amount of nicotine that they are getting. So, we get kind of a different aspect of quitting. Because cigarettes have an absolute amount of nicotine per cigarette. You are able to calculate based on how many cigarettes you smoke in a day; we can identify how much nicotine you have consumed. With vaping, especially the refillable ones, sometimes they can lead to less frequent use of the device, but sometimes, greater nicotine content when they are using it. So this leads to somewhat of — and I don’t want to come across as if all vapors do it in secret, but it does allow them to be more secretive in their delivery of the device because it creates that vapor and there are devices where they can exhale into it where they could be using it in public and you wouldn’t know it.

We get more frequent use of nicotine often times with our vapers. So, it is important to recognize that vaping is not a therapy or a substitution. When looking at vaping, they allow us to adjust the nicotine and oftentimes they can lead to the popcorn lung. There are electronic nicotine devices easily made at home so they can become very popular as a form of delivery and middle schools and high schools. Even my daughter last year when she was in fifth grade, she had a student who brought a vape to school. So it is not impossible. It is harder to identify how much nicotine they are actually consuming because maybe I take three vapes from my pen every hour. OK, how much nicotine is in your pen, how much are using? And it may be, I have no idea. I take a few puffs during the day. From 50 puffs a day to 200 puffs a day. Nicotine replacement therapy gets very tricky when you look at vaping.

The next concept is second and third hand smoke. No amount of secondhand smoke or vaping is safe to inhale. Again, most smokers believe when they moved outside, they limited the risk. But third hand smoke refers to the residue that is left on fabric, clothing, skin and hair after smoking. It is left on your clothing or any surface you’ve come into contact with, anyone that comes in contact with your clothing or your vehicle or your skin, it can be transferred to them and also to other objects. So, for example, this individual that kept their grandchildren and their grandchildren’s toys on their couch, they sat on the couch and played on that couch and now that content is being transferred to their grandchildren via that method. So, it puts children at greater risk of developing respiratory related illnesses whenever their parents’ smoke. And a lot of times — I even had a friend who said, I never smoke indoors or in the car with my kids. There is still an increased risk of occurrence of respiratory related illness and infection with children and also an increase in the risks of SIDS deaths among children who are exposed to third hand smoke. This study investigated third hand smoke, where they took pillows and put them in the homes of individuals who had quit smoking. And whenever they quit smoking, the pillow was replaced in their homes. They never smoked again. They left these pillows in for a series of four weeks and then took them and analyzed them for nicotine content. They found that the greatest amount of nicotine content was found on the pillow itself, the cover on the inside of it still had, but even the pillow itself still had amounts of nicotine on it. So, you can imagine smokers who have quit smoking, but they had previously smoked in their home? The only way to truly get rid of all the nicotine content would be to replace all the contents of your home. So again, third hand smoke is something a lot of people don’t readily recognize. That really hit home with these individuals, especially parents, because they didn’t realize they were exposing their children to these toxins because of their ability to smoke even when they were taking efforts to smoke away from the children.

Lastly, I think it is important to prepare all individuals for withdrawal symptoms. Sometimes people try to avoid putting emphasis on withdrawal symptoms because it’s not pleasant. It’s not the fun part of any of this, but I feel like it is very important to be upfront about it and helping these individuals overcome these obstacles, letting them know that this is what will happen. Letting them know that you understand why they might need nicotine replacement therapy and what nicotine replacement therapy to use. We can look at gums, we can look at breaking their routine, simply keeping cigarettes in your car and not bringing them into your home, having to take that extra effort to go outside and get them. Changing up a routine can be somewhat frustrating. But also, it is a successful method of getting individuals to break that habit of, I just wake up and smoke. There is a lot of planning that kind of goes into the quit routine. And so, this is where, beyond my own experience, I think it is very important to rely on those trained tobacco treatment specialists as well as physicians. And medical personnel that can help with nicotine replacement therapy. But I also understand that in under resourced communities, readily seeking medical assistance and nicotine replacement therapy is not something some people have access to. So, I use the gums and the lozenges personally because I felt like I was able to closely match their nicotine content and help them understand what the potential side effects would be, as well as the medications themselves. I was uncomfortable with these individuals because a lot of them didn’t have regular physician oversight of their care. And so that is where this also gets a bit difficult, because I didn’t want to be responsible for any potential side effects that they might have. But I wanted to be upfront and honest, when you use lozenges, here is what you should see, and if you experience symptoms, this is when you should stop and seek additional assistance. So, it is important with nicotine replacement therapy that you actually are weaning them off the nicotine and not just replacing the nicotine. The nicotine should be weaning slowly, not just replacing one form or another.

So my biggest point I wanted to make with you guys before we run out of time, is that spending time with these individuals allows you to become the trusted messenger. Smoking cessation, regardless of how you choose to go about it, you should never approach it from a judgmental, scolding perspective. You want to remain up to date on the facts and what programs are available in your area and how you can partner with those programs. You want to seek out additional information and what resources are available and then offer encouragement at each phase. It shouldn’t be, you fail and then we are done. For most it takes 8-11 attempts before they are successful at quitting. Help them determine their why. Sometimes right now they need to address their emotional concerns. They need to address mental concerns. What personal issues they have going on. Trying to quit on top of that is not necessarily something they should do. But helping them identify their goals and their why and letting them know when they should come back to you. You want to become that reliable resource within your community.

Here are a few websites to a few different smoking cessation resources from the American Lung Association, the CDC, and the American Cancer Society. And there are different ways you can get involved with your communities if you’re looking to start a program or you want to get involved and see how you can help support. Teaching tobacco cessation materials, there are a few ideas I have here. It’s very important to get connected with your area of interest and once you get connected with that community, you become a trusted member. You would be surprised how easily things fall into place after that.

Here are my references. And I know I am kind of short on time, but you have any questions?

De De: Thank you so much. This has been a great information session on tobacco cessation in under resourced communities. We appreciate your time. We do have time for a couple of questions. One of the things that we have people asking about, do you have an online or telehealth option for your program in the event that people are not able to attend face-to-face?

Dr. Fino: So, I don’t currently offer it, but I do know that the American Lung Association has it. I don’t offer it with the way I teach my program because I am partnered with my students — but the American Lung Association supports the use of virtual classes, so if I have the opportunity to offer more classes, that is certainly something that I could do.

De De: Great. And then, one of the other questions here is also looking at nicotine-free campuses. If you’re either a school nurse or working in a facility that you have a nicotine free campus, specifically for school nurses, what would you suggest that school nurses possibly do to help their students with tobacco cessation or nicotine withdrawal? Is there anything that can be done?

Dr. Fino: That is kind of a gray area, because to some degree, you need to have parental involvement for appropriate nicotine replacement therapy, if it is needed. I find that sometimes for the youth, their nicotine consumption may not be as high as it would be for individuals who can legally obtain all of these materials. Sometimes it is, sometimes it isn’t. So, I think it is important to address and come up with a strategy that you can use campus wide, as well as potentially seeking expert advice from a medical from may be physicians on what the appropriate cessation would be. But I honestly find that just weaning them off is best, especially with nicotine and tobacco free campuses. It is only as much as you enforce it, unfortunately. It has to be appropriately enforced in order for it to be effective.

De De: Right. So, one of the last questions is, would you be willing to share results or evaluation of the program that you have so that people can learn from that? This might be something that we could include in our follow-up resources that are posted. What are your thoughts?

Dr. Fino: Sure. The program and the way that I am currently teaching it in transitional housing, I am only coming up on my second year, I don’t have a lot of results. I am fairly new in that aspect, but I would be willing to share them as I get it. Yes. Absolutely.

De De: Great, thank you so much. We want to thank you, Jessica, for your time today, this has been an informative webinar. Our next webinar is on October 19th at 4:30 p.m. Eastern when we will welcome Dr. Clint Dunn to discuss atopic dermatitis. You will receive an email from Zoom within a few days with a link to the recording and evaluation, and supplemental resources. Thank you again from all of us at Allergy & Asthma Network. Join us as we work every day to breathe better together.