The two main causes of lung cancer

0:00 Welcome back to Sarah Has Questions. Today's topic is lung cancer. You may have been a smoker in the past and think you're out of the woods because you quit. Well, it might not be that simple, and turns out there is something in our homes that could be contributing to your risk. We have a lot to cover in this episode. So let's get into it. I'm Sarah King, and I have a lot of questions. What exactly happens when you orgasm physically? Will popping a knuckle or a joint give us arthritis? What can we learn from our poop? The size of your body doesn't necessarily indicate your measure of health. Yes. And what are your thoughts on that? Cleansing. Do we need to do anything special to our nether regions? In this show, I get to ask all these questions to WakeMed doctors who happen to know everything about everything. Sarah has questions is a production of Capital Broadcasting Company and Mix 101.5. It's presented by WakeMed. Today, I am talking with doctor Vicki Fowler. You are a family medical physician with WakeMed, and we were just talking off here how important fed family medicine is. As a family medicine physician, I'm sure you you see lung cancer from time to time.

1:09 Apparently, it is the leading cause of cancer deaths worldwide. Why do you think that is? There's a lot of factors contributing to the leading cause of death being from lung cancer and, as you mentioned, lung cancer is a leading cause of death for, leading cancer cause of death in the United States, in North Carolina, and actually in the world, variety of factors. And one of the things I wanna really talk about today with you is the importance of knowing your own risk and how to find out through your physician if you qualify for screening as well as ways to lower your risk. Okay. Well, let's start with how you figure out someone has lung cancer. What are the symptoms? What could we be looking out for? Well, the symptoms of lung cancer, and this is one of the issues, can be very, common and they can be associated with other conditions such as asthma, emphysema.

2:05 The issues that you want to go to your primary care physician and mention if you develop them is a persistent cough Okay. That does not resolve. Certainly, if you're coughing up blood Oh. That is something that needs attention. Yeah. Shortness of breath, that is new. Some of the more concerning would be unexplained weight loss is another thing to be watched out for and if you are having weight loss that's not explainable by diet and exercise, you want to check with your physician. Unfortunately, something like unexplained weight loss would be a later sign. Early signs are basically often associated with other conditions such as asthma and allergies, but you wanna get that checked out. So like wheezing, because I think asthma, I think wheezing and like, being hoarse. Yeah. And that's true. Hoarseness. The bottom line is if you have a symptom that's going on and you don't know what it's from, rather than googling it, looking it up on the Internet, maybe trying to treat yourself, that's why we, I emphasize all my patients, you know, how important it is to have a primary care physician or a trusted health care provider that you could go talk to about these symptoms and figure out what's causing it. And do you think that the fact that it it mirrors all these other ailments that is why it takes often a lot of time to get a a lung cancer diagnosis? There's a lot of factors involved. Number 1, one of the reasons I'm really excited to be here and the fact that we have November's lung cancer awareness month. And I see that you're wearing turquoise Yes. And you have the white ribbon, not the pink ribbon, the white ribbon. That

3:36 is lung cancer awareness. Yes. That is correct. So the the big issue about lung cancer is the lack of awareness by, many people about the burden of lung cancer, the risk factors an individual may have for lung cancer. So knowledge is power. Yes, always. Knowing that lung cancer is the leading cause of death and that it can be cured if detected early and ways to know if you're at risk is key. So some of the risk factors for lung cancer are basically some things that are out of our control. Okay. The number one cause of lung cancer is in our control largely, which is smoking. Tobacco use is the number one cause of lung cancer, but the second leading cause of lung cancer is environmental exposure to radon.

4:22 Oh. Radon. Where do you find radon? Where does that happen? Radon is radon is everywhere to some degree. It is the breakdown of uranium in the soil and it is prevalent in certain areas more than others. Interesting. You own it's odorless, it's colorless, and you have no idea if you're breathing radon, unless you actually check your home for radon. Radon concentrations are higher in certain areas of our state, such as where I'm from, the northwestern corner of the state. Wonderful. But really in throughout the southeast is a high area of radon, exposure. The important part is smoking being the number one risk factor, But if you smoke and you have radon in your home, it actually is tenfold risk. Wow. The other thing to consider is if your home has radon and you smoke, you're actually putting other members of your family at risk, especially children. So there is an increased lifetime risk of lung cancer in a child exposed to secondhand smoke and exposed to radon. Well, I mean, I grew up in the eighties in the south. Yes. Yes. So, yeah, I I had a lot of secondhand smoke in my day. Yes. So, but, I mean, like, I don't smoke it as an as an adult, so I'm assuming that's gonna help me out. Absolutely. Okay. So one of the, complicated factors factors about talking about lung cancer screening is at present time, we have guidelines for screening for lung cancer. But right

5:54 now, our main focus is on the highest risk individuals, which are individuals who have smoked during their lifetime. So over a decade ago, we had clear cut guidelines of the individuals that are high risk, the screening that's recommended, and unfortunately, the uptake of that screening is very very low. So while radon exposure is a risk factor, your genetics are a risk factor and your behaviors are a risk factor, the most controllable risk factor is smoking. Okay. So, I wanna make sure those people who do smoke, not secondhand smoke, but those people who have smoked in their lifetime or do smoke understand what their risk may be and if they need to get screened. And so so basically, by doing that, you would, you would just go to your doctor and say, I used to smoke in college, you know, not all the time, but sometimes I might be talking about myself. You know?

6:45 Yes. Like if I was at a party, I'd be known to have a cigarette, so I should tell my doctor this. Well, it's that's important. Absolutely. But we have clear cut guidelines and it's very simple. The number is something called 20 pack years and you may I may want to talk to you about pack years. Yeah. What is a pack year? So obviously We had one last year with NC State. It was quite the pack year. It was a great pack year. And this is a whole different pack year. Okay. But, and we hope we have another great Oh, heck yeah. Wolf pack year. Anyway, sorry. Back to our topic. But our topic, tobacco so with many things, it's it's the dose of your exposure. For instance, radon. I mentioned radon exposure.

7:26 Sure. If you have a high radon exposure, which is over a measure of 4 picocuries, then you should have your home mitigated, the radon exposure lowered. So if you if you wanna know more about that, there's certainly websites available. Okay. So one can figure out how to test their home, who to go to test their home Okay. To lower that risk. However, we don't include radon exposure in our risk factor calculation because it is a risk factor, but we have to really focus on the highest risk individuals on screening. It's also very difficult to measure. Like, if you you can't go to every single patient's house and measure their radon. Yeah. They have to do that. Yeah. That takes But also, we have to talk about where schools Yeah. Where do you work? Yeah. So we there are policies pushing forward trying to get schools tested. So I hope so. That would be important. Yeah. We don't we don't really have that. But the individual factor, the most important risk factor is a 20 pack year smoking history. And I know a lot of your interest is on women's health. Yes, of course. And of course, me as a woman and a female physician taking care of many women. I, will point out the reason we have the guideline, which I'll explain called 20 pack years, is that women and actually black individuals are at higher risk of lung cancer at a lower exposure.

8:42 Meaning, our previous guidelines over a decade ago said that you needed to have, 30 pack years. 30 pack years and that's basically smoking a pack of cigarettes per day for 30 years or 2 packs of cigarettes a day for 15. Gotcha. Simple math. Gotcha. But if you've exposed your lungs to the carcinogens in tobacco, in cigarette smoke, if you had exposed your lungs to those cancer causing chemicals Uh-huh. To that degree, you were at much greater risk. Well, studies were done looking at different populations and it turned out that in women and blacks, it was much lower risk. We were missing those individuals. So now the risk factor is 20. If you smoked a pack of cigarettes a day for 20 years, say you started in college Yeah. But then you stopped when you were 40. It's 20 years. 20 years. I know 20 years creeps up on you. It does. So it did. It has for me. I don't know about you, but it has for me. Oh my gosh. Yeah. So, now there are different guidelines, and that's where the importance of going to your doctor and discussing it.

9:49 And also, my importance as a physician who's an advocate for cancer screenings, can point out. The US Preventive Services Task Force says, that if you have stopped smoking more than 15 years ago, that you don't need screening. Oh, and you don't believe that? Well, no. Yeah. You don't believe that. The American Cancer Society came out with new guidelines last year in November, November 1st, and it said, based upon clear, observational studies and information that we can see in the past, even though it is good to quit smoking, and even though your risk goes down over time, it doesn't go away. Yeah. And individuals, even after 15 years, as they age, still have elevated risk. Mhmm. So I really now, in for importantly, your insurance companies and the payers, they are pretty much bound to follow USPSTF guidelines. Who is that? That's the in the US Preventive Services Task Force. Gotcha. And they make the guide they make the guideline of if you've quit smoking 15 years, you don't your risk has gone down and you don't need screening. What is probably gonna happen, I think, in the next few years Mhmm. Will be this agreement. I'm I'm hopeful there'll be an agreement. Okay. And an individual can be an advocate. You know, you can say to your doctor, well, well, I understand that my insurance may not cover this because I quit smoking 20 years ago, but if you think I'm at risk, how much does that cost me? Yeah. And

11:19 how do I get screened? Yeah. Like, you may wanna know. Well, we need yeah. We're gonna get to that for sure. That is made me think of the adage that I learned a long time ago that you will pay for what you did in your twenties when you're in your fifties. Yes. Yes. Yes. I were my family, doctor when I was growing up, I joined him in practice when I went back home, and he used to say to his patients, you know, those first 40 years are pretty easy, but those last 40 years take work. So we do and I love that part of of I love that adage. I love that. I I actually take care of a lot of patients over 40. Yeah. A lot of people in their twenties thirties as well, but but I find that individuals in their forties fifties start really seeing Looking the you know, wanting to be active and be healthy and be well in their seventies Yeah. So they can travel after they retire Exactly.

12:02 And really start becoming more aware. Interestingly enough, this is one of the really important reasons we need to advocate for limiting tobacco exposure to our youth Yes. And limiting, you know, vaping with our youth. That was my next question. Yes. So you're mentioning the chemicals in tobacco smoke. Yes. Does that include vaping? Because I've heard of this thing called popcorn lung. Yes. Yes. I know it's kinda 2 questions in 1. So 2 in 1. So one thing I'll I'll point out to, like, any health care professionals listening or patients that are interested, some people smoke cigars, they smoke cigarillos, they don't smoke cigarettes. They smoke marijuana.

12:53 But there are ways of looking at someone's cigarette use and their cigar use and figuring that exposure. Now when you talk about vaping, we don't know the long term implications of vaping. And the other thing that's really concerning, I've had some patients of mine that are trying to quit smoking, and very wisely, they say, I have friends who transitioned to vaping. I've had people tell me that their doctors have told them. Early in the days of vaping. It was early on that they said that vaping is safer, and they just took that and ran with it. Well, there are an incredible number of toxins and carcinogens in a cigarette. Like, the first time in training that I saw the graph of the number of carcinogens in a cigarette, and I'm remembering my tobacco farm I grew up on and my dad raised tobacco. Right. And it didn't look so dangerous out in the field. Sticky, leafy plant. Yeah. It's not so bad.

13:49 Well, it's not so bad, but all of the chemicals that go into either, you know, there's pesticides in raising the tobacco, but then in the process and what happens to form that cigarette, there's a lot of carcinogens. So they they pack a lot of carcinogens in that little tiny thing. So that's the real, one of the real risks. But as far as vaping, especially whatever materials they're using in that vape pen, we know that some of those materials, especially certain flavors, certain additives, they're not supposed to be in your lungs. Yeah. These chemicals were never meant to be in your lungs. Taste them. Yes. So they're meant to be tasted, not inhaled. Yes. So inhaling these chemicals, the long term implications are something we're gonna find out about. And the other factor, some of my patients who wanna quit smoking say, you know, I don't wanna transition to vaping because I've noticed my friends actually vape a lot more than they used to smoke because they can vape in places that don't allow smoking. That's true. So you actually get a higher, tendency to become addicted to nicotine. If you're vaping like a nicotine product, you're using it more. Interesting. And nicotine is very addictive. Yeah. It is. And, you know, just like, I mean, that makes me think of the whole semaglutide Ozempic thing. It's so new. We're looking we're waiting on the long term. So everyone who's doing it now, vaping included, you're basically a guinea pig. Yeah.

15:09 Well, we do know, I mean, from popcorn lung and you've mentioned I mean, it popcorn lung? Lung? Popcorn lung, I I the the lung on an x-ray looks like popcorn is my, you know, remembrance. Holes in it? It just is scarred and it looks abnormal, which gets around to imaging. Like, you you know, we talked about if you go to your physician, you're coughing up blood, you know, we first start often with an x-ray. Okay. But unfortunately, chest x rays, while they might show popcorn lung and they might show pneumonia, they often miss cancer. And I can remember back in the early 2000s when I was back practicing in my hometown, there was a huge study, you know, going on looking at a better way to look for lung cancer. Okay. And many institutions in our state were involved in that work.

15:55 Low dose CT. Low dose CT scans are the way we find early lung nodules and things that are going to turn into cancer or maybe cancer. What is a CT scan? Ah, CT. Like the CAT scan. You hear people talking about a CAT scan. So is that different than an MRI? Yes. Okay. And an MRI is the tube. Well, you lay on a table. The MRI is the tube that's very closely, like, you're very close. To get to get to get to get to get to get to get to get to get to get to get to get to that. So, CT stands for, basically computed tomography. Okay. It's a way of looking at your body, kinda slicing it up into pieces and looking at the pieces as an x-ray. Gotcha. So you can and you can have thin slices, you can have thick slices. Interesting. Okay. And a low dose CT means that there's less radiation involved. That's wonderful. Right? So basically, the risk the risk of I mean, there's risk from radiation. Of course. Of course.

16:49 And the if you went for a CT scan every year, every single year, regular dose CT, you actually can increase your risk of cancer Right. Because of the radiation exposure. So that's a concern. So the low dose CT is basically equivalent to getting on an airplane in North Carolina and flying to California, that amount of radiation exposure. So you can do these low dose CTs annually for many years and not feel like you're providing necessarily an increased risk of cancer. Gotcha. We actually have that information. We I would talk to my patients about that. If you enroll in this program, we're monitoring you every year over a certain amount of time. There is some increased risk, but it's very low and the benefits of fighting cancer early most of my patients The benefits outweigh the risk in most cases.

17:37 Exactly. And there is a shared decision making. I mean, with everything you do with your primary care physician or healthcare provider, there needs to be shared decision making. Am I at risk for lung cancer? How do we screen for that? And if you find cancer or a precancerous appearing nodule, is the patient healthy enough to undergo biopsy and treatment and will they go through biopsy and treatment? It's a lot of factors to factor in. That's why you need a physician, a primary care physician to go through this. And our pulmonologists are wonderful and our CT surgeons here at WakeMed are wonderful, and they all have the skills to also do that. Mhmm. But they generally see patients after the diagnosis. You're not going to a pulmonologist to find out if you're at risk. Right. You're going your fam your medical Medical provider. Yeah.

18:22 Exactly. We'll be right back because you know I have more questions. So how often are non smokers diagnosed percentage wise? Exactly. Well, of course, there's 2 different kinds of lung cancer. There's small cell lung cancer, which more associated with smoking Okay. And there's non small cell lung cancer, which often people hear about, like, adenocarcinoma. That is the most common type of lung cancer. Non small cell lung cancer is about 75 to 80% of cancers. It's less aggressive. Good. It metastasizes and grows slower. Mhmm. So that's wonderful. Mhmm. If we find it early, it's often curative and and it's it it has a better prognosis. Okay. Small cell lung cancer is about 20% of lung cancer. So there's 2 different kind. Small cell lung cancer is more aggressive. Okay. It's more associated with smoking.

19:19 Okay. But those are the 2 different types. Okay. Okay. And your question was My question was is how often is a nonsmoker being diagnosed in general? So generally speaking, 80%, even maybe in some studies up to 90%, but at least 80% of lung cancer is associated with smoking. Wow. That's a big percentage. Yeah. That's why that's your number one risk. Yeah. 20% of cancers and unfortunately, this may be growing, but 20% of cancers are not associated with smoking. Other factors, the main one being radon exposure. I just think that's so crazy that something that we have, we can't even notice. Like you need to take it when you're house shopping basically. Get your radon to get rid of it. Number 1, in North Carolina, actually, our, we advocated in the state of North Carolina and the real estate, organization in North Carolina, to be a real estate agent in North Carolina, you must be trained on radon, the importance of radon, and you have to talk with your home buyers have to know, are supposed to know the amount of radon in the home they're going to buy. You can ask for that information. Did not know that. And if it is high, you can ask the owner to put it in a mitigation system, which is basically fans.

20:34 Fans that you are installed so that this gas, this odorless gas is pushed out from under the foundation. It basically comes up from the ground, water, and and and soil, and it gets into your home through cracks in the foundation. Oh my god. So You've got me wanting to get a detector for my house. How much radon is here? No. I mean, I don't know. You don't know. Well, you need to do that. We actually some people you can buy them at your hardware store. You can get them from your health department. You can check for 24 hours. You can check for a month. There's actually a company here in Raleigh, they'll come out to your house and check for you and if you're high, they can put you in touch with people. You really want a reputable person to do the mitigation. Yeah. Of course. Yeah.

21:15 Okay. So So there you go. Lung cancer's number 1. Radon and genetic factors are also a risk. And then occupational exposure. Oh my goodness. Firefighters, individuals who work in construction. Airline people, it sounds like. Yeah. Asbestos exposure. There are other factors that are important to consider. Okay. Mhmm. And can you can you do your own mitigation in terms of lung cancer? Like, is diet how does how does diet and exercise affect your chances? Yeah. Well, you know, diet and exercise actually are critically important for reducing the incidence of basically all cancers Yeah. Cardiovascular disease and dementia.

21:56 So It's just good for you. It's just good for you. So I spend a lot of time talking with patients about diet and exercise Sure. And lowering stress because all of these factors can play in. The number one thing that a person can do though is, radon mitigation, avoiding tobacco use, stopping smoking if you smoke as far as lung cancer. Also, knowing your family history. We don't count family history in the specific calculation. Well, I'm saying the insurance companies don't count it. Well, who's gonna pay for it because if you're in America and it can destroy you. Yeah. Insurance companies will pay for your CT if you meet the, you are over the age of 50. We didn't get to that. It's 20 pack years and between the ages of 5080. Those are the basic requirements for your insurance. I see. Medicare, Medicaid. They will pay for an annual low dose CT if you're over the age of 50 and under the age of 80 Okay. And if you've smoked at least 20 pack years and currently it still has that 15 years since quit. Okay. That's the insurance.

22:59 But I was gonna say, if you want to pay for it yourself, there are many, many imaging facilities here in Wake County that you can just go in. Well, your doctor would have to order it. Okay. But your doctor can say, well, Sarah, if you think because, you know, these members of your family and your radon and, you know, x, y, and z Just want some peace of mind. You you and your doctor may say no, Sarah. You have nothing to worry about, like smoking in college, you know, but if they looked at all the factors and you had a a decision, but that again is just someone that I talk about, you know, we're talking more and more about personalized medicine and precision medicine. Which I'm very excited about because we are all so very different. Yeah. So I think it's more of a conversation, but the real important push for the American Cancer Society and and all the organizations I work with and as a healthcare provider is the age 50 to 80, 20 pack years and I do wanna emphasize that it's important for a patient to know their family history, but to also understand their smoking history. Yeah.

23:58 And when they talk to their healthcare professional that they say, well, you know, I'm only smoking a half a pack a day now because if you go into my office and you tell my staff, well, I've been smoking since I was 20 and I smoke a half a pack a day and say you're 45, you know, or 40, they're gonna look at that and they're go, okay, 20 years, half a pack, 10 pack years. Well, be honest. Well, in your twenties to thirties, if you were smoking a pack and a half, you actually met the criteria. This is being this is throughout all of our health care systems. Yeah. We have trouble as your physicians getting that information. Well, because there's shame attached to it. Yes. We so we try to use words now instead of you're a smoker.

24:42 We try to say person who smoked or a person who smoked. No? Oh, because I guess it wouldn't matter if you do that to chew and stuff. Well, that's more oral cancers. Yeah. But person who smokes, means you smoke, but that doesn't define you, if that makes sense. That makes absolute sense. You're not you're not a smoker. You're a person. You're a person who smokes. And so it's not your identity. Yes. And I do think there's number 1, there's a lot of fear about lung cancer. Yes. Because people think it's a death sentence. And it's not if you have the non small cell. Well, it is it is well, the non small cell chances. Non small cell is less aggressive, but the point is if you catch either non small cell or small cell cancer at early stage and we can talk a little bit about that, stage 1 cancers are curable. Curable with, you know, seeing our lung cancer surgeons, you know, seeing our specialists and you can remove the cancer and you can be cured. We talk a lot about breast cancer screening, colorectal cancer screening, which is a law in it that I have you know, we spend so much time working on those. Very important.

25:43 Yes. Very important. Our our breast cancer screening rates in the country, our colorectal cancer screening rates in the country are like 75 to 80%. Now they should be a 100% for everyone. But still better than lung cancer. So our survival at 5 years for breast cancer and colorectal cancer is up in the 75 to 80%. Fabulous. Our screening rates in the country and in North Carolina for lung cancer screening of the at risk population is around 8 to 14% and the risk of that being the risk the likelihood of you still being alive once you've had a lung cancer diagnosis currently because of the lack of knowledge and awareness about screening Sure. And, like, catching it early matters. Catching it early matters, is the mortality is basically like 26 percent Oh, wow. At 5 years. But if you catch it at stage 1, the mortality is maybe like, you know, your survival is probably 70 to 90%. Okay. Yeah. You can get your early lung cancer diagnosed, get a lung resection and be back on the golf course in a week and that's straight from one of my colleagues, Doctor. Alden Mayer here at WakeMed. She did that? She, she's amazing. She's our, yeah, she is, we have wonderful lung cancer screening team, and and, you know, they really advocate for primary care physicians to talk to their patients, patients to bring up the question. But we all know, visits are rushed. There's a lot to cover. What I was getting ready to say.

27:10 There's a lot to get in there. Everybody's talking fast. Go. Go. Yeah. So this is why that annual wellness visit with your health care professional get a long period of time and you just talk about yourself. You know, longer in our in our long in the current framework of medicine is 30 minutes. But, you know, you know, instead of that 15 minute visit, you get that 30 minute visit. But what what what many people do with that wellness visit is they bring up 3 or 4 problems that they've been holding on to. Yes. I'm guilty. Well, see, that's the problem. Some of my patients will come in and they go, well, you know, for the last 4 months, I've had this, and for a year, I've had that, and then this rash came up, and can we go through that today? Okay. And what I usually say is, well, we're gonna it's gonna cut into the prevention part of our time together. Yeah. So I tell patients, don't hold them off or just ask as you go. Well, just come in. Yeah. Come in and see us if you have a problem, and then devote that 30 minutes or 40 Mhmm. To all of these things. Okay. Yeah. Well, real quickly, why are blacks more susceptible?

28:15 So there's a lot of issues to consider. We feel like there's, you know, the inequities for lung cancer are pretty profound. Basically, whereas white men are more likely to have breast have lung cancer, black men are more likely to die of lung cancer. So some of it is access. Yeah, of course. You know, access to care, social determinants of health, they're probably genetic factors where less tobacco exposure leads to more likelihood of developing cancer, but right now, if you look in North Carolina data, you can evaluate what's the likelihood of being diagnosed early. You know, you're more likely, if you're black, to be diagnosed at a later time.

28:57 It may be because of not having access to care, maybe not asking the right questions, maybe not realizing that a lower PAC year history is a risk factor for you. So we're working on that and also in North Carolina, it turns out that our Native American population, they really have a higher incidence of, lung cancer and there's a lot of research going on to try to make sure access is improved, Yeah. Awareness campaigns. So socioeconomic things. Socioeconomic. You know, 20% of a person's, health is defined by the time I spend with them in the exam room and the medicines we prescribe. 80% of it is their habits, their genetics, and their environment. Okay. So November's a month that's really important because there's a lot of social media important because there's a lot of social media campaigns, there's a lot of outreach. People may say, how do I access these services? How do I find a place to get a low dose CT? Yeah. And WakeMed has a wonderful, wonderful, lung cancer screening program. Okay. They get referrals from all over. You know, I think that and I work with the, you know, the advisory committee for cancer coordination control for the state and we do a lot of outreach with federally qualified health centers, health departments, regional areas. So just because you're rural North Carolina, there are resources. You can get resources.

30:16 It's about knowing who to ask, where to go, and that there is a need. Okay. And I have one last Sure. Short question. You mentioned that tobacco use is the number one thing you need to to cut out, right, because of all the stuff put in there. Does that mean that if you smoke, quote, unquote, natural cigarettes, the ones that are, like, just straight up tobacco in the packs? Because I know someone's gonna want me to ask this question. Oh, it's a good question. Know the answer that if if that's gonna lower your risk at all? Well, I don't know the answer. Okay. That's good to know. That's a good question. Fine. I know that in my reading that it's clear that people who roll their own tobacco and certainly, well, we do know that people who roll tobacco for, like, religious ceremonies, there is data showing that there is less likely likelihood of cancer thought to be with those. I don't think that reduced risk is none, but it's certainly less of a risk than your normal cigarettes you go buy over the counter. Okay, perfect. So I think that the keys I want people to take home is don't smoke. Don't smoke. If you do smoke, stop.

31:19 If you don't start to begin with. Also, many resources in the state of North Carolina and certainly here at WakeMed for assistance with cessation. People have a lot of guilt. Mhmm. Individuals will say, I can do this. I just have to set my mind to it. It's not easy sometimes. And I try it easy sometimes. It's not and it's not something to be shamed about. We have a wonderful, program here at WakeMed that I try to encourage my patients to go to talk to. It's basically, in many or many areas have this, 1800 QUIT now is through the state. An individual will work with you by your phone, you don't have to go anywhere and they'll talk about it. Make it as easy as possible. They'll talk to you about what are your triggers, how can we help you when you have that trigger to smoke. Always smoke after I eat a meal. I always smoke when I'm out at a party. How do we work with those triggers to decrease that? I have a patient who only smokes in his car, but he smokes really fast in his car. Like, you can smoke 3 cigarettes in your car as you drove over here. But, you know, people will have those triggers. Yeah. But most of the time, they also have individuals in their lives who love them. And, the American Cancer Society has this wonderful campaign is I love you get screened. I love you get screened. And so it's like I love you stop smoking. Yeah. And and people know that they should quit. Yeah.

32:41 But knowledge isn't enough. They need resources. So we have a smoking cessation program at WakeMed that's very helpful. Okay. These are trained individuals. Medications help. Most people can't crack that nicotine habit by themselves. Yeah. But there are medications like, Chantix and, you know, nicotine replacement over the counter. But, you know, is there even as a physician, I would want guidance on Yeah. Of course. The dose, you know. Of course. We actually have, ways of calculating if you had a certain amount of cigarette exposure, like you smoke a half a pack, how much nicotine should you replace it with? Right. There has to be some Yeah. You don't wanna just take, like, 5 pieces of gum Yeah. And then, like, keel over from nauseousness. Yeah. That's exactly right. Right. Right. So, you know, there's a lot to unpack. Lung cancer screening is the most complicated screening I've ever, dealt with in my career because there's so many factors to consider. Breast cancer, it's a woman, she's a certain age, let's screen. Right. This has this is all about how many, how long. It's so complicated.

33:44 It is, but it's not impossible. And the most important thing is to talk to your physician. Well, I appreciate your time today. This has been I could ask you. I I literally have a whole another page of questions I didn't have time to get to. Oh gosh. So that means we have to have you back. That'd be great. Radon, pack years, who knew? I'm off to order some radon testing kits from my house right now. Doctor Vicki Fowler was my guest today, and you can find her at wake med.org. We'll link to some of the things she mentioned in the show notes, including a link to WakeMed's smoking cessation program. It's virtual, so you don't have to live here in Raleigh to do it. Speaking of links, we'd love it if you shared the link to this episode with a friend. Just hit the share button and pass it along. See you next time.