The Peter Attia Drive - #161 - AMA #23： All Things Nicotine： deep dive into its cognitive and physical benefits, risks, and mechanisms of action

00:00:00.000 Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.

00:00:16.500 I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can

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00:00:25.440 or you can learn more now by going to peteratiyahmd.com forward slash subscribe.

00:00:31.140 So without further delay, here's today's sneak peek of the ask me anything episode.

00:00:39.180 Welcome to ask me anything AMA episode number 23. I'm joined once again by Bob Kaplan. In today's

00:00:46.920 episode, we discuss nicotine and all things related to nicotine. We talk about smoking, of course,

00:00:53.340 and we talk about how nicotine works. It turns out nicotine is a super complicated and very

00:00:59.520 interesting molecule. It has effects in the brain. It has effects in the body. We talk about how

00:01:05.080 nicotine works and we talk about what the studies say about its benefits to people. That might sound

00:01:11.360 like a contradictory term, given that we know tobacco is so harmful, but in this episode,

00:01:16.220 we distill all of that into something that I hope is digestible. If you're a subscriber and you want

00:01:21.740 to watch the full video of this podcast, you can find it in the show notes. And if you're not a

00:01:25.840 subscriber, you can watch a sneak peek of the video on YouTube. So without further delay, I hope you'll

00:01:31.180 enjoy AMA number 23. Hey, Peter. Hey, man. How are you? I'm doing well. How are you? Good. Except for

00:01:44.520 the fact that my shin is on fire, it is killing me at the moment. I think, you know, I've discovered

00:01:51.440 recently the use of long high socks for sumo deadlifts, which has been a game changer. And then

00:01:58.380 today when I was doing my warmup set, I just forgot to put the socks on. So I literally had 135 pounds on

00:02:05.900 the bar and two reps into it ripped a hole in my shins that by the time I put the bar down, there

00:02:14.580 was blood down to the floor. And I was like, dude, how could you forget to put your socks on? Like

00:02:19.780 your magic favorite socks. So anyway, I'm lamenting my badness there, but other than that, I'm good.

00:02:26.960 That's good. I don't think we have any questions around that, but I do have a question. Do you do

00:02:30.320 sumo deadlift? Do you do a standard as well? And you still using your hex bar?

00:02:34.280 I go back and forth. So I used to love to deadlift twice a week, alternating two of the three between

00:02:40.900 a sumo, a standard and a hex bar. And I go in phases. Like right now I'm really loving sumo and

00:02:49.340 I've fallen out of love with trap bar. I don't know why I just was having trouble kind of finding it

00:02:57.280 again. And whereas I feel really good in the sumo and I actually haven't done straight bar in probably

00:03:02.280 like six months. I mean, like a traditional narrow, narrow stance, straight bar, but I like mixing

00:03:07.540 them up. I mean, I just, I sort of think deadlift is, if you could only, it's a sort of silly,

00:03:12.460 unrealistic question. I mean, you'd only do one exercise. What would it be?

00:03:15.900 It would definitely be variations of deadlifts for me. Hey, that rhyme.

00:03:21.920 That's very nice. Yeah.

00:03:23.320 It's poetic.

00:03:24.100 I'm good like that.

00:03:24.820 So we have a, we have an interesting episode today.

00:03:28.740 We do. We do. We consolidated a bunch of questions around nicotine. We've received a bunch of

00:03:36.020 questions and typically people will just, I think would say that I don't even think people would ask,

00:03:41.760 you know, is smoking bad for you? But there actually are a lot of things, a lot of questions

00:03:45.120 around nicotine and are there benefits to nicotine? And in particular, we got questions around

00:03:49.960 that people have heard about it, it improving cognition. And if that's possible, is there any

00:03:54.900 literature on that? There's also a question about nicotine improving fat oxidation and can it

00:04:01.020 actually help with weight loss? And another one, which is really interesting that I think we'll get

00:04:06.340 to is, is it possible that smoking is protective against COVID-19?

00:04:11.800 Yeah. This is where I think the AMAs are fun because that turned into a really interesting

00:04:17.080 deep dive and I would have never even thought of that. So it was nice to see a whole bunch of

00:04:21.860 people had asked that question. And then of course we got to, we got to look into it.

00:04:26.520 You know, I said, before we jump into this, I will just say from a personal standpoint,

00:04:29.960 I became interested in nicotine about maybe 11 years ago and realized that if you could strip away

00:04:39.680 the addictive nature of nicotine, and we'll get into that a little bit more, the actual molecule

00:04:44.860 was quite interesting and started chewing nicotine gum intermittently. And obviously if anybody's

00:04:51.780 ever chewed nicotine gum, who's not a smoker, you realize you got to go really easy because

00:04:56.560 it can make you quite nauseous and things like that. And so I would, you know, for the next three or four

00:05:02.300 years, I was on and off nicotine gum, you know, somewhere between four and eight milligrams a day

00:05:07.600 and found it to be quite beneficial as far as sort of sharpening my sword, so to speak,

00:05:12.760 and just got me a little focused. And I was fortunate in that I never really felt even this

00:05:18.660 slightest semblance of addiction to it. So I could chew it for 10 days in a row and then stop it for

00:05:24.880 a month and didn't even really notice I was not taking it. So I don't know that that's necessarily

00:05:29.440 something that everyone can experience. Recently, I have discovered these little pouches, nicotine

00:05:35.960 containing pouches, which you can sort of put in your mouth. They also have lozenges and things like

00:05:41.440 that that I much prefer because then you don't get the, there was always some, I always thought the

00:05:45.000 gum tasted kind of gross. It also had a little sugar in it. It was a little too sweet. And these

00:05:49.220 pouches are mostly flavorless. They have a bit of an aroma. And to be clear, they're not, they're not

00:05:54.640 like dip or chew, you know, and we'll get into what that difference is. So you're just basically just

00:05:59.320 getting a pretty high dose of nicotine and it's bypassing the liver. So it actually hits you quicker.

00:06:05.140 Yeah. I've tried the gum and the, and the lozenges and I found with a gum, same as you. And also I

00:06:12.320 think on the instructions, the part of it is you chew it a little bit, get a little bit of the

00:06:15.520 nicotine out of it. And then you're, you're supposed to park it, which sounds like what you're probably

00:06:19.140 doing with that pouch or what you do with the lozenge. Cause otherwise I think it, if you're just

00:06:23.480 chewing it like regular gum and chewing it a lot, it, it made me nauseous.

00:06:26.880 Yeah. Let's help people understand a little bit why nicotine isn't dangerous. Let's start with that,

00:06:33.580 right? Cause I, as you alluded to at the outset, you would not be blamed for having a knee jerk

00:06:39.940 reaction to the notion that nicotine is a bad thing. So you want to talk for a second, Bob,

00:06:45.560 about the difference between nicotine and tobacco? Yes. So when you're looking at nicotine and tobacco

00:06:52.220 and you're looking at, well, when you're looking at tobacco, obviously cigarettes contain leaves from

00:06:56.800 tobacco plants and tobacco also contains nicotine. So you've got that connection there. And something that

00:07:02.400 I didn't realize is that tobacco is actually, it's in the nightshade family of plants. And so when you

00:07:07.960 look at potatoes and tomatoes and eggplants, there's actually, there's nicotine in there,

00:07:12.220 but the nicotine, the level of nicotine in those plants are nowhere near tobacco. So nicotine makes

00:07:18.620 up, it says about one to 3% of the dry weight of tobacco. Whereas these nightshades, it's like

00:07:24.820 millions of a percent, very trace amounts. But interestingly, even the U S surgeon general said,

00:07:30.920 there's not enough evidence or inadequate evidence to infer a causal relationship between nicotine

00:07:36.980 exposure and risk for cancer. So I think like a lot of other people, so I have you beat Peter by

00:07:42.300 maybe a decade or two, as far as my interest in nicotine, but it was more about, I smoked in high

00:07:47.920 school a little bit, smoked cigarettes. And I can certainly speak to the addictive nature of

00:07:52.320 cigarettes. But at that time, and probably years after that, I would just think, you know, when people

00:07:56.840 would talk about nicotine being bad for you, I'd say, sure, that it's, it's in cigarettes and it's

00:08:01.320 probably one of the many carcinogens in tobacco smoke. And if you go to the, I think it's like

00:08:06.660 they got the WHO where they've got their long list of potential and known carcinogens. And I think they,

00:08:13.580 it says they have at least 69 chemicals that, that are contained in tobacco smoke that are carcinogens,

00:08:19.920 but nicotine is actually not one of them.

00:08:22.320 That's an important point, right? This is something really worth reiterating, right? So

00:08:26.520 the, the U S department of health and human services says they've identified at least 69

00:08:32.660 chemicals contained within the tobacco plant, i.e. things that make it into cigarettes that are

00:08:39.080 carcinogens and nicotine is not one of those things. So it's interesting in that nicotine is the

00:08:44.580 thing that I think we're going to talk about has some benefits. It also, unfortunately has that

00:08:50.280 addictive part of it. So it brings you back to the tobacco, but in and of itself, it doesn't cause

00:08:55.180 cancer.

00:08:56.320 Right. And if you look at the WHO, this could be an, you know, an entirely different podcast, but

00:09:00.040 red meat and process meat process meat is a, I think it's a class one. And then there's the,

00:09:05.220 the next class down, which is red meat. So I figured I'd go to the list on the WHO. And if there's

00:09:10.400 anything, you know, on nicotine being carcinogenic, I would think that the WHO would have it listed

00:09:14.840 there, but it's, it's not. So I think that's what you're basically saying is the WHO will

00:09:20.180 go so far as to claim that red meat is a carcinogen. And we've written so much about

00:09:26.240 this topic and basically said the evidence suggesting that red meat is carcinogenic is

00:09:31.600 so weak that it's very difficult to take it seriously. And if there's any carcinogenic

00:09:37.280 properties of meat, it's really low signal. And you're saying if they, if they can't even

00:09:42.800 recognize nicotine as carcinogenic, given their sensitivity for identifying carcinogens, the

00:09:48.660 likelihood that it has any cancer causing properties is approaching epsilon, if not

00:09:53.140 zero. Yeah, that's right.

00:09:55.400 Okay. So where do all these nicotine replacement products come from? Is it safe to say that this

00:10:00.880 entire industry of gums and patches and lozenges, inhalers, nasal sprays, little pouch that I'm

00:10:07.540 sucking on right now, these are basically tools to get people to stop smoking, right?

00:10:13.440 Yeah. So if you, yeah, you look at the literature and there's this NRT, they call it nicotine replacement 0.96

00:10:18.400 therapy. So you've got nicotine, which is addictive. And so you, you could implicate that

00:10:24.440 in getting people to smoke and stay smoking and make it hard for them to stop. But they're

00:10:28.960 actually exploiting nicotine, in fact, to help people quit smoking. So you've got all these

00:10:33.860 products that some of them, most, the ones that we'll talk about for the most part, I think

00:10:37.740 are FDA approved for nicotine replacement therapy to get people to help quit smoking. And there's

00:10:43.540 some reviews and probably a lot of people are familiar with the Cochran collaboration. They put

00:10:48.380 together a review and found high quality evidence that this NRT increases the chances of successfully

00:10:55.840 quitting smoking by about 50 to 60%. And I think anybody who smokes knows how, how hard it is to quit.

00:11:02.020 But, but hang on, Bob, we're going to have to make sure we make sure people know we're talking

00:11:06.100 relative success increase. Can you put that in absolute terms, please?

00:11:11.500 Yes. So the, for the six months, the absolute quit rate, this is just in general at six months.

00:11:19.340 So you try to quit and they look at people after six months and see if they're, if they've gone back

00:11:23.240 to smoking and the people who have quit for six months and haven't returned to smoking, the absolute

00:11:28.160 rate is about three to 5%, which is pretty depressing. Um, and so in that case, that means that NRT may

00:11:35.240 increase the rate from an absolute perspective by a couple of percentage points, maybe two to 3%.

00:11:40.140 Yeah. So another great teaching point here, which is you could read the headline and say,

00:11:45.120 wow, nicotine replacement therapy increases your odds of quitting by 50 to 60%. And that sounds like

00:11:50.380 an awfully big number, but you have to always ask the question, what does that mean at an absolute

00:11:55.900 level? And if the absolute rate, the absolute success rate of people quitting tobacco at six months is

00:12:01.740 two to 3% and you increase that by 50 to 60%. Well, look, it's, you know, it's, it's an improvement,

00:12:07.820 but in the big picture, it tells us that it is very hard to quit smoking using NRT. And I gotta be

00:12:14.440 honest with you. I don't know why it's not higher, Bob. Like, I don't know why the relative improvement

00:12:21.780 with NRT isn't like a thousand percent or, you know, like 500%. Like why do you have a, do you have a

00:12:30.540 sense of why maybe as a former smoker, why when you, if you, if you take someone who smokes and

00:12:35.260 you give them NRT, you can't get 50% absolute quit rate at six months? It's hard for me to say.

00:12:43.360 It's been so long since I smoked. And I think it'd be interesting to look into. I wonder if people

00:12:47.820 think that like they, you know, they go to a lozenge or they go and, and the lozenges that I've

00:12:52.480 tried and the gum that I've tried, I usually just try the smallest dose. So the, the lozenges that I

00:12:56.720 have, I think are, they come in for the most part, two milligram and four milligram. And I take the

00:13:01.600 two milligram one and I think we'll get to this, but a cigarette supposedly has about one milligram

00:13:07.260 of nicotine contained within the cigarette. But I think it's a different route of administration.

00:13:12.340 And I think that people might think that it's, they probably say something to the effect of,

00:13:16.360 it's just not the same. And they go back to the smoking. And I think some people think it's like,

00:13:21.280 well, maybe it's the oral fixation or things like that.

00:13:23.640 Or do you think it's just that, that when you're smoking, the inhalation is the fastest

00:13:29.360 route of administration. So the rush and the buzz from the nicotine, when you inhale it

00:13:34.180 and, you know, across that entire alveolar surface area, nothing can compete with that.

00:13:39.520 And so all of these little piddly NRT therapies are just insufficient to reach the same level.

00:13:46.400 I think that plays a role. I think that they're working on, if not, if they haven't already

00:13:50.020 developed this, but patches and maybe some of the, the sprays, the nasal sprays and things like

00:13:55.040 that, that they're part of why they're, you know, you have these different routes of

00:13:58.640 administration is they're trying to mimic getting a speedier delivery to it. So maybe those will be

00:14:04.420 more efficacious in the future.

00:14:07.520 Well, it'd be interesting actually to, at some point do a podcast on smoking cessation because

00:14:12.680 we take this for granted that, gosh, I think at its peak, which would have been about 1964,

00:14:19.400 1965, I believe up to 59, if not 60% of Americans over the age of 18 smoked cigarettes, which,

00:14:28.280 you know, I don't know how to qualify that. I don't know what constituted smoking. You know,

00:14:31.760 did that include people who just smoked socially, like, uh, at a bar, you know, a couple of cigarettes

00:14:36.260 a week versus the pack a day smoker. But, but nevertheless, that's a pretty astonishing quantity.

00:14:41.000 I think the most recent numbers are about 18 to 19% of people over 18. Is that sound about

00:14:46.940 directionally right?

00:14:48.480 Yeah, I think so. I think we'll get to it with COVID that they're, they look at some

00:14:52.980 prevalence numbers too, because they're comparing rates of hospital admission compared to the

00:14:57.640 general population. And I think it, it depends, but I think Americans might be like, like around

00:15:01.760 13% to 15%. It's definitely gone down. And it, it reminded me too, I think the podcast with

00:15:07.180 Nir Barzilai, and he was talking about his centenarians and talking about, is it the genes

00:15:11.960 or the environment? And he would talk about a lot of the centenarians that he was studying and saying

00:15:16.100 that it doesn't look so much like its environment. And one of his, you know, one of the things that he

00:15:20.640 pointed out was a lot of the centenarians had smoked. And I don't know if that was never smokers,

00:15:25.660 but if you look at, if you look historically, you would think almost like, how, how is it possible

00:15:30.820 these people never smoked in their lifetime? It was so prevalent. It was kind of amazing.

00:15:35.740 Yeah. I mean, we haven't had a lot of current smokers enter our practice. A few that have,

00:15:42.960 obviously that's literally the first thing we address. If you're a smoker and you're interested

00:15:47.480 in longevity, there's harder to find a lower hanging piece of fruit than smoking cessation.

00:15:53.040 As you move to improve someone's health, we've used Wellbutrin, which is an antidepressant.

00:15:58.380 I used to know the numbers. In fact, I think we have a little white paper somewhere in the practice

00:16:02.500 that gave us a bit of an assessment on how to combine NRT with Wellbutrin. But this might be

00:16:08.300 an interesting topic, but okay. So what can we say about the cognitive benefits of nicotine? So here

00:16:16.300 I am a few minutes after ingesting my little nicotine little patch. It's sitting in here. It's,

00:16:22.800 again, it's bypassing my liver. It's getting into my system much quicker because it's being directly

00:16:27.300 absorbed. Maybe it's placebo, but I got to tell you, Bob, I'm feeling pretty sharp right now.

00:16:33.540 I don't know what to say. I'm just feeling sharp. Yeah.

00:16:36.600 You got a differential equation for me to solve?

00:16:39.580 Not offhand, but yeah.

00:16:41.580 I could recite Stokes' theorem like that. I'm ready to go.

00:16:45.100 It's going to go entirely different AMA podcast.

00:16:47.460 Yeah. You looked into this. So how many studies have tried to ask this question directionally?

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The Peter Attia Drive - May 10, 2021

#161 - AMA #23： All Things Nicotine： deep dive into its cognitive and physical benefits, risks, and mechanisms of action

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