#161 - AMA #23： All Things Nicotine： deep dive into its cognitive and physical benefits, risks, and mechanisms of action
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Summary
In today's episode, I'm joined by Bob Kaplan to discuss nicotine and all things related to it. We talk about how nicotine works, what the studies say about its benefits to people, and whether or not it's actually bad for you.
Transcript
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Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.
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I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can
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So without further delay, here's today's sneak peek of the ask me anything episode.
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Welcome to ask me anything AMA episode number 23. I'm joined once again by Bob Kaplan. In today's
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episode, we discuss nicotine and all things related to nicotine. We talk about smoking, of course,
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and we talk about how nicotine works. It turns out nicotine is a super complicated and very
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interesting molecule. It has effects in the brain. It has effects in the body. We talk about how
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nicotine works and we talk about what the studies say about its benefits to people. That might sound
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like a contradictory term, given that we know tobacco is so harmful, but in this episode,
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we distill all of that into something that I hope is digestible. If you're a subscriber and you want
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to watch the full video of this podcast, you can find it in the show notes. And if you're not a
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subscriber, you can watch a sneak peek of the video on YouTube. So without further delay, I hope you'll
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enjoy AMA number 23. Hey, Peter. Hey, man. How are you? I'm doing well. How are you? Good. Except for
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the fact that my shin is on fire, it is killing me at the moment. I think, you know, I've discovered
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recently the use of long high socks for sumo deadlifts, which has been a game changer. And then
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today when I was doing my warmup set, I just forgot to put the socks on. So I literally had 135 pounds on
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the bar and two reps into it ripped a hole in my shins that by the time I put the bar down, there
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was blood down to the floor. And I was like, dude, how could you forget to put your socks on? Like
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your magic favorite socks. So anyway, I'm lamenting my badness there, but other than that, I'm good.
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That's good. I don't think we have any questions around that, but I do have a question. Do you do
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sumo deadlift? Do you do a standard as well? And you still using your hex bar?
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I go back and forth. So I used to love to deadlift twice a week, alternating two of the three between
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a sumo, a standard and a hex bar. And I go in phases. Like right now I'm really loving sumo and
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I've fallen out of love with trap bar. I don't know why I just was having trouble kind of finding it
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again. And whereas I feel really good in the sumo and I actually haven't done straight bar in probably
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like six months. I mean, like a traditional narrow, narrow stance, straight bar, but I like mixing
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them up. I mean, I just, I sort of think deadlift is, if you could only, it's a sort of silly,
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unrealistic question. I mean, you'd only do one exercise. What would it be?
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It would definitely be variations of deadlifts for me. Hey, that rhyme.
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So we have a, we have an interesting episode today.
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We do. We do. We consolidated a bunch of questions around nicotine. We've received a bunch of
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questions and typically people will just, I think would say that I don't even think people would ask,
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you know, is smoking bad for you? But there actually are a lot of things, a lot of questions
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around nicotine and are there benefits to nicotine? And in particular, we got questions around
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that people have heard about it, it improving cognition. And if that's possible, is there any
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literature on that? There's also a question about nicotine improving fat oxidation and can it
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actually help with weight loss? And another one, which is really interesting that I think we'll get
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to is, is it possible that smoking is protective against COVID-19?
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Yeah. This is where I think the AMAs are fun because that turned into a really interesting
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deep dive and I would have never even thought of that. So it was nice to see a whole bunch of
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people had asked that question. And then of course we got to, we got to look into it.
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You know, I said, before we jump into this, I will just say from a personal standpoint,
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I became interested in nicotine about maybe 11 years ago and realized that if you could strip away
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the addictive nature of nicotine, and we'll get into that a little bit more, the actual molecule
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was quite interesting and started chewing nicotine gum intermittently. And obviously if anybody's
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ever chewed nicotine gum, who's not a smoker, you realize you got to go really easy because
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it can make you quite nauseous and things like that. And so I would, you know, for the next three or four
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years, I was on and off nicotine gum, you know, somewhere between four and eight milligrams a day
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and found it to be quite beneficial as far as sort of sharpening my sword, so to speak,
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and just got me a little focused. And I was fortunate in that I never really felt even this
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slightest semblance of addiction to it. So I could chew it for 10 days in a row and then stop it for
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a month and didn't even really notice I was not taking it. So I don't know that that's necessarily
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something that everyone can experience. Recently, I have discovered these little pouches, nicotine
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containing pouches, which you can sort of put in your mouth. They also have lozenges and things like
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that that I much prefer because then you don't get the, there was always some, I always thought the
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gum tasted kind of gross. It also had a little sugar in it. It was a little too sweet. And these
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pouches are mostly flavorless. They have a bit of an aroma. And to be clear, they're not, they're not
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like dip or chew, you know, and we'll get into what that difference is. So you're just basically just
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getting a pretty high dose of nicotine and it's bypassing the liver. So it actually hits you quicker.
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Yeah. I've tried the gum and the, and the lozenges and I found with a gum, same as you. And also I
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think on the instructions, the part of it is you chew it a little bit, get a little bit of the
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nicotine out of it. And then you're, you're supposed to park it, which sounds like what you're probably
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doing with that pouch or what you do with the lozenge. Cause otherwise I think it, if you're just
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chewing it like regular gum and chewing it a lot, it, it made me nauseous.
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Yeah. Let's help people understand a little bit why nicotine isn't dangerous. Let's start with that,
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right? Cause I, as you alluded to at the outset, you would not be blamed for having a knee jerk
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reaction to the notion that nicotine is a bad thing. So you want to talk for a second, Bob,
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about the difference between nicotine and tobacco? Yes. So when you're looking at nicotine and tobacco
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and you're looking at, well, when you're looking at tobacco, obviously cigarettes contain leaves from
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tobacco plants and tobacco also contains nicotine. So you've got that connection there. And something that
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I didn't realize is that tobacco is actually, it's in the nightshade family of plants. And so when you
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look at potatoes and tomatoes and eggplants, there's actually, there's nicotine in there,
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but the nicotine, the level of nicotine in those plants are nowhere near tobacco. So nicotine makes
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up, it says about one to 3% of the dry weight of tobacco. Whereas these nightshades, it's like
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millions of a percent, very trace amounts. But interestingly, even the U S surgeon general said,
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there's not enough evidence or inadequate evidence to infer a causal relationship between nicotine
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exposure and risk for cancer. So I think like a lot of other people, so I have you beat Peter by
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maybe a decade or two, as far as my interest in nicotine, but it was more about, I smoked in high
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school a little bit, smoked cigarettes. And I can certainly speak to the addictive nature of
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cigarettes. But at that time, and probably years after that, I would just think, you know, when people
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would talk about nicotine being bad for you, I'd say, sure, that it's, it's in cigarettes and it's
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probably one of the many carcinogens in tobacco smoke. And if you go to the, I think it's like
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they got the WHO where they've got their long list of potential and known carcinogens. And I think they,
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it says they have at least 69 chemicals that, that are contained in tobacco smoke that are carcinogens,
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That's an important point, right? This is something really worth reiterating, right? So
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the, the U S department of health and human services says they've identified at least 69
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chemicals contained within the tobacco plant, i.e. things that make it into cigarettes that are
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carcinogens and nicotine is not one of those things. So it's interesting in that nicotine is the
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thing that I think we're going to talk about has some benefits. It also, unfortunately has that
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addictive part of it. So it brings you back to the tobacco, but in and of itself, it doesn't cause
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Right. And if you look at the WHO, this could be an, you know, an entirely different podcast, but
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red meat and process meat process meat is a, I think it's a class one. And then there's the,
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the next class down, which is red meat. So I figured I'd go to the list on the WHO. And if there's
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anything, you know, on nicotine being carcinogenic, I would think that the WHO would have it listed
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there, but it's, it's not. So I think that's what you're basically saying is the WHO will
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go so far as to claim that red meat is a carcinogen. And we've written so much about
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this topic and basically said the evidence suggesting that red meat is carcinogenic is
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so weak that it's very difficult to take it seriously. And if there's any carcinogenic
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properties of meat, it's really low signal. And you're saying if they, if they can't even
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recognize nicotine as carcinogenic, given their sensitivity for identifying carcinogens, the
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likelihood that it has any cancer causing properties is approaching epsilon, if not
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Okay. So where do all these nicotine replacement products come from? Is it safe to say that this
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entire industry of gums and patches and lozenges, inhalers, nasal sprays, little pouch that I'm
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sucking on right now, these are basically tools to get people to stop smoking, right?
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Yeah. So if you, yeah, you look at the literature and there's this NRT, they call it nicotine replacement
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therapy. So you've got nicotine, which is addictive. And so you, you could implicate that
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in getting people to smoke and stay smoking and make it hard for them to stop. But they're
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actually exploiting nicotine, in fact, to help people quit smoking. So you've got all these
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products that some of them, most, the ones that we'll talk about for the most part, I think
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are FDA approved for nicotine replacement therapy to get people to help quit smoking. And there's
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some reviews and probably a lot of people are familiar with the Cochran collaboration. They put
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together a review and found high quality evidence that this NRT increases the chances of successfully
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quitting smoking by about 50 to 60%. And I think anybody who smokes knows how, how hard it is to quit.
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But, but hang on, Bob, we're going to have to make sure we make sure people know we're talking
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relative success increase. Can you put that in absolute terms, please?
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Yes. So the, for the six months, the absolute quit rate, this is just in general at six months.
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So you try to quit and they look at people after six months and see if they're, if they've gone back
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to smoking and the people who have quit for six months and haven't returned to smoking, the absolute
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rate is about three to 5%, which is pretty depressing. Um, and so in that case, that means that NRT may
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increase the rate from an absolute perspective by a couple of percentage points, maybe two to 3%.
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Yeah. So another great teaching point here, which is you could read the headline and say,
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wow, nicotine replacement therapy increases your odds of quitting by 50 to 60%. And that sounds like
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an awfully big number, but you have to always ask the question, what does that mean at an absolute
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level? And if the absolute rate, the absolute success rate of people quitting tobacco at six months is
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two to 3% and you increase that by 50 to 60%. Well, look, it's, you know, it's, it's an improvement,
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but in the big picture, it tells us that it is very hard to quit smoking using NRT. And I gotta be
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honest with you. I don't know why it's not higher, Bob. Like, I don't know why the relative improvement
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with NRT isn't like a thousand percent or, you know, like 500%. Like why do you have a, do you have a
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sense of why maybe as a former smoker, why when you, if you, if you take someone who smokes and
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you give them NRT, you can't get 50% absolute quit rate at six months? It's hard for me to say.
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It's been so long since I smoked. And I think it'd be interesting to look into. I wonder if people
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think that like they, you know, they go to a lozenge or they go and, and the lozenges that I've
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tried and the gum that I've tried, I usually just try the smallest dose. So the, the lozenges that I
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have, I think are, they come in for the most part, two milligram and four milligram. And I take the
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two milligram one and I think we'll get to this, but a cigarette supposedly has about one milligram
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of nicotine contained within the cigarette. But I think it's a different route of administration.
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And I think that people might think that it's, they probably say something to the effect of,
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it's just not the same. And they go back to the smoking. And I think some people think it's like,
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well, maybe it's the oral fixation or things like that.
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Or do you think it's just that, that when you're smoking, the inhalation is the fastest
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route of administration. So the rush and the buzz from the nicotine, when you inhale it
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and, you know, across that entire alveolar surface area, nothing can compete with that.
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And so all of these little piddly NRT therapies are just insufficient to reach the same level.
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I think that plays a role. I think that they're working on, if not, if they haven't already
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developed this, but patches and maybe some of the, the sprays, the nasal sprays and things like
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that, that they're part of why they're, you know, you have these different routes of
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administration is they're trying to mimic getting a speedier delivery to it. So maybe those will be
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Well, it'd be interesting actually to, at some point do a podcast on smoking cessation because
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we take this for granted that, gosh, I think at its peak, which would have been about 1964,
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1965, I believe up to 59, if not 60% of Americans over the age of 18 smoked cigarettes, which,
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you know, I don't know how to qualify that. I don't know what constituted smoking. You know,
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did that include people who just smoked socially, like, uh, at a bar, you know, a couple of cigarettes
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a week versus the pack a day smoker. But, but nevertheless, that's a pretty astonishing quantity.
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I think the most recent numbers are about 18 to 19% of people over 18. Is that sound about
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Yeah, I think so. I think we'll get to it with COVID that they're, they look at some
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prevalence numbers too, because they're comparing rates of hospital admission compared to the
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general population. And I think it, it depends, but I think Americans might be like, like around
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13% to 15%. It's definitely gone down. And it, it reminded me too, I think the podcast with
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Nir Barzilai, and he was talking about his centenarians and talking about, is it the genes
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or the environment? And he would talk about a lot of the centenarians that he was studying and saying
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that it doesn't look so much like its environment. And one of his, you know, one of the things that he
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pointed out was a lot of the centenarians had smoked. And I don't know if that was never smokers,
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but if you look at, if you look historically, you would think almost like, how, how is it possible
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these people never smoked in their lifetime? It was so prevalent. It was kind of amazing.
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Yeah. I mean, we haven't had a lot of current smokers enter our practice. A few that have,
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obviously that's literally the first thing we address. If you're a smoker and you're interested
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in longevity, there's harder to find a lower hanging piece of fruit than smoking cessation.
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As you move to improve someone's health, we've used Wellbutrin, which is an antidepressant.
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I used to know the numbers. In fact, I think we have a little white paper somewhere in the practice
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that gave us a bit of an assessment on how to combine NRT with Wellbutrin. But this might be
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an interesting topic, but okay. So what can we say about the cognitive benefits of nicotine? So here
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I am a few minutes after ingesting my little nicotine little patch. It's sitting in here. It's,
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again, it's bypassing my liver. It's getting into my system much quicker because it's being directly
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absorbed. Maybe it's placebo, but I got to tell you, Bob, I'm feeling pretty sharp right now.
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I don't know what to say. I'm just feeling sharp. Yeah.
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You got a differential equation for me to solve?
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I could recite Stokes' theorem like that. I'm ready to go.
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It's going to go entirely different AMA podcast.
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Yeah. You looked into this. So how many studies have tried to ask this question directionally?
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