• Leah Daniel

Meet the TTS Faculty: Dr. Adam Goldstein

Each of our program founders and faculty members brings a wealth of expertise and accomplishments to the Duke-UNC Tobacco Treatment Specialist Training Program. In this space, we will be introducing each member of our team individually through a series of questions to learn more about their interests in tobacco cessation work. We hope that you enjoy getting to know each member of the TTS faculty a bit better over the course of this series!

Dr. Adam O. Goldstein, Director, Tobacco Intervention Programs, UNC Chapel Hill

Next in our Meet the Faculty series is Dr. Adam O. Goldstein, Director of Tobacco Intervention Programs at UNC-Chapel Hill. As Director of Tobacco Intervention Programs, he oversees both the UNC Tobacco Treatment Program as well as the Tobacco Prevention and Evaluation Program. Adam O. Goldstein, MD, MPH is a Professor of Family Medicine at the UNC School of Medicine in Chapel Hill, North Carolina. His research has had extensive local, regional, and national influence through print, radio, and television media, with over 200 articles, essays, book chapters, and books, featured in CNN, CBS Evening News, the New York Times and Wall Street Journal. He founded and is Co-Host of UNC Health Care’s

YOUR HEALTH®, a syndicated, weekly one- hour radio show on health, healing, medical care, and ethics (www.yourhealthradio.org).

We asked Dr. Goldstein some questions about his involvement with tobacco cessation work.

How did you become a part of the Duke-UNC TTS program?

I had a desire to start an in-depth tobacco training program at UNC for a number of years. I knew what was out there, and I felt that what was missing was one of the things that our program excels at—really experiential training. I thought that we had some unique aspects to offer, but I didn't want to do a training that would compete with Duke. I knew that we weren't going to have two separate programs in this area, so I talked with Sally Herndon at the NC Tobacco Prevention and Control Branch (TPCB), and we agreed to approach Duke about a collaboration. Dr. James Davis had just recently started the Duke Smoking Cessation Program.

When I approached Dr. James Davis at Duke about it, he asked how it was going to work. I said, “Well, it's up to us to make it work.” There are only one or two examples across the two universities where collaborative efforts occur, such as the Robertson Scholars or some work within the Jewish Studies program. What we did then was to sit down and, along with the TPCB, commit to really doing a program that was built upon the strengths of both programs. Duke’s program focuses much more on neurobiology, pharmacology, and clinical trials. The UNC program focuses more on program implementation science and on behavioral support interventions. And then the TPCB completed the trifecta of what makes our program unique and different from everything else out there.

I would say it's succeeded beyond my imagination, in some respects, because you don't know when you have an idea how well it's going to go. One special thing that we were able to offer was a discount for people serving underserved populations. To my awareness, we’re the only program in the country that does that. And we’ve continued that each year, which I think draws people who are serving those populations to our training. We also ensure that we address those issues more completely in our own training as well.

How long have you been working in tobacco cessation?

I've been working in cessation since I was a second-year medical student, over three decades now. It's interesting because on one level, we've made really tremendous progress in terms of what we know to help people quit. On the other hand, it’s such an addictive habit that we're only able to get 25 - 30% of people to quit. I will say that I used to think there were some people who would never quit - the person who smoked three packs of unfiltered Camels, for example. However, scientific advances have proven that wrong. When it came out varenicline was a major advance, and people who wanted to quit actually could quit no matter their level of addiction. I myself have changed over time to believe that there is no one that can't quit at any age. It's more a limitation of our own thinking than it is a limitation of the science.

What began your interest in this work?

As a first- or second-year medical student, you aren’t allowed to do very much, and you know even less. And even when you finish medical school, you don't know very much. However, you learn quickly that tobacco is the primary preventable cause of death and disease and that a strong message from a credible provider actually helps people quit. Quitting smoking is the greatest thing that you can do to protect your health and your loved ones. I recognized that message didn't have to wait until I was a doctor or through training. I became quite interested in cessation then, and I also recognized how little students were trained in an approach that had evidence behind it. They didn't know even the basic science on cessation. So I was really interested as a medical student in doing research on cessation.

I think I'm interested in systems changes because at that time, in the early 1990s, doctors could still smoke in hospitals. There were doctors’ smoking rooms at hospitals, and it was the surgeons and the cardiologists who were smoking. I thought that was a disgrace! Yet it was stopping policy change. We were not able to initially move our hospitals to smoke-free hospitals and tobacco-free hospitals if we couldn't get rid of the doctors’ lounges, or doctors writing on patients’ charts that they were allowed to smoke. I was really interested in clinical, training, and policy issues, and then ultimately research issues as they relate to how to drive policy, increase systems adoption, and be more effective on a population level. Those are issues that, the more I got into them, the more I realized the impact that we could have really moving the bar, not just for our own clinical populations, but for clinical populations across the country.

What makes you passionate about this work?

On the level of clinical interventions, one thing is that, clearly, you get to see people change. You get to see people quit and see them do things that they're so happy and so proud of - things that they may not have thought possible - and they were able to do so because you worked with them. Another thing is getting the opportunity to train others. As a result of that, you see others who get it, understand it, and are starting to do it themselves. Finally, it’s very exciting to see that we can change how this is done in society. We can do this at population levels and develop simple research that, when enacted, makes a huge difference.

For example, we were able to move smoking cessation questions from the social section of a patient’s medical history and create a series of vital signs that each provider sees at the very beginning. Now in a patient’s chart you see pulse, respiration, temperature, and smoking status. We are able to ask if a patient smokes, if they’re interested in quitting, and if the provider advised them to quit, all in the initial interview. There are five key aspects of smoking cessation counseling that you can do, and now three of them are in the vital signs. We showed that when you do that, you dramatically increase success. That’s such a simple intervention with such profound impacts, and that's incredibly gratifying when you can do that.

Is there anything else you’d like to share with people about yourself or your work?

I think that it's important for everyone to always think about when and where they can make an impact in their daily life. Sometimes it’s right in front of you. I think about how when my kids were younger, I would take them to the movies to see G-rated animated cartoons, and I would see characters smoking cigars and cigarettes in these cartoons. I didn’t understand why in these G-rated feature films, they had characters smoking and drinking. They were treating these characters as adults but yet exposing young kids to these messages. That led to a research study where we looked at the history of tobacco and alcohol use in G-rated animated films, which led to a major publication in JAMA and our work being featured on CBS, CNN, and The New York Times, and eventually changing the way people see this issue. It’s not a joke to be exposing our youngest kids to subliminal cues about smoking and drinking in very positive ways. We found that in 60 years, there was not a single mention of the negative health consequences of either product.

I think that there are so many things that are in front of us every day, whether it’s walking into a building and seeing people smoking outside, or being exposed to second- or thirdhand smoke when we go somewhere, that we just accept as normal rather than asking, “How can I change that?” That’s what I’m really interested in and passionate about: How can I help people to realize that smoke-free air is a right. You have that right and can demand that right. You can make that change yourself.

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Duke-UNC Tobacco Treatment Specialist Training Program  |  2424 Erwin Road, Durham, NC 27705  |  cttsprogram@duke.edu  |  919.668.5042