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

Episode Date: May 10, 2021

In this “Ask Me Anything” (AMA) episode, Peter and Bob dive deep into nicotine, a complicated and interesting molecule that has effects on both the brain and the body. They analyze the results of the studies that describe nicotine’s cognitive benefits and potential for inducing weight loss. They talk about a smoking cessation technique called nicotine replacement therapy and give a full breakdown of the various routes of administration, dosing, and safety. Finally, they explore the fascinating and counterintuitive observation that cigarette smokers are less likely to get a severe case of COVID-19. If you’re not a subscriber and listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA #23 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here. We discuss: How Peter first became interested in the potential benefits of nicotine [1:15]; Untangling nicotine from tobacco [6:00]; Nicotine replacement therapy (NRT) for quitting smoking: products, protocols, and a review of the literature [9:30]; The cognitive benefits of nicotine: Overview of the literature [15:50]; Where nicotine has the most positive impact on cognition [30:30]; Possible mechanisms conferring the benefits of nicotine [37:00]; How modafinil and other nootropics compare to nicotine [47:15]; How nicotine may induce weight loss [54:00]; Relationship between smoking and COVID-19: Analyzing the observation that smoking appears protective against COVID-19 [1:01:45]; Breakdown of the various nicotine replacement therapies: route of administration, dosing, and safety [1:11:30]; Concluding thoughts on nicotine: use cases, addictive properties, and more [1:19:45]; and More. Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/ama23  Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to a sneak peek, ask me anything, or AMA episode of the Drive Podcast. I'm your host, Peter Atia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peteratia-md.com forward slash subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to Ask Me Anything, AMA episode number 23, I'm joined once again by Bob Kaplan. In today's episode, we discuss nicotine and all things related to nicotine. We talk about smoking, of course, and we talk about how nicotine works.

Turns out nicotine is a super complicated and very interesting molecule. It has effects in the brain, it has effects in the body. We talk about how nicotine works and we talk about what the studies say about its benefits to people. That might sound like a contradictory term, given that we know tobacco is so harmful. But in this episode, we distill all of that into something that I hope is digestible. If you're a subscriber and you want to watch the full video of this podcast, you can find it in the show notes. And if you're not a subscriber, you can watch a sneak peak of the video on YouTube.

So without further delay, I hope you'll enjoy AMA number 23. Hey Peter. Hey man, how are you? I'm doing well. How are you? Good, except for the fact that my shin is on fire, it is killing me at the moment. I think you know I've discovered recently

the use of long high socks for Sumo deadlifts, which has been a game changer. And then today when I was doing my warm-up set, I just forgot to put the socks on. So I literally had 135 pounds on the bar and two reps into it ripped a hole in my shins. But the time I put the bar down there was blood down to the floor. And I was like, dude, how could you forget to put your socks on? Like your magic favorite socks. So anyway, I'm lamenting my badness there, but other than that, I'm

good. That's good. I don't think we have any questions around that, but I do have a question. Do you do, do you do sumo deadlift? Do you do a standard as well? And you still use in your hex bar? I go back and forth. So I used to love to deadlift twice a week alternating two of the three between a sumo, a standard and and a hex bar, and I go in phases. Right now I'm really loving sumo, and I've fallen out of love with trap bar. I don't know why. I just was having trouble finding it again, and whereas I feel really good in the sumo,

and I actually haven't done straight bar in probably like six months. I mean, like a traditional narrow, narrow stance straight bar. But I like mixing them up. I mean, I just, I sort of think deadlift is, if you could only, so this is sort of silly unrealistic question. I mean, you'd only do one exercise. What would it be? It would definitely be variations of deadlifts for me.

Hey, that rhymed. That's very nice. Yeah, it's poetic. I'm good like that. So we have an interesting episode today. We do. We do. We consolidated a bunch of questions around nicotine.

We treat a bunch of questions and typically people will just, I think, would say that I don't think people would ask, you know, it's smoking bad for you. But there actually are a lot of questions around nicotine and are there benefits to nicotine? And in particular, we got questions around the people have heard about it, improving cognition. And if that's possible, is there any literature on that? There's also a question about nicotine improving fat oxidation and can it actually help with weight loss? And another one, which is really interesting

that I think we'll get to, is it possible that smoking is protective against COVID-19? Yeah, this is where I think the AMA is our fun because that turned into a really interesting deep dive and I would have never even thought of that. So it was nice to see a whole bunch of people had asked that question. And then of course we got to look into it. You know, I say, before we jump into this, I will just say,

from a personal standpoint, I became interested in nicotine about maybe 11 years ago and realize that if you could strip away the addictive nature of nicotine and we'll get into that a little bit more, the actual molecule was quite interesting and started chewing nicotine, and we'll get into that a little bit more. The actual molecule was quite interesting, and started chewing nicotine gum intermittently. And obviously, if anybody's ever chewed nicotine gum who's not a smoker, you realize you got to go really easy because it can make you quite nauseous and things like that. And so I would, you know, for the next three or four years, I was on and off nicotine, you know, somewhere between four and eight milligrams a day and found it's be quite beneficial as far as sort of sharpening my sword, so to speak, and just got me a little focused.

And I was fortunate in that I never really felt even this slightest semblance of addiction to it. So I could chew it for 10 days in a row and then stop it for a month and didn't even really notice I was not taking it. So I don't know that that's necessarily something that everyone can experience. Recently, I have discovered these little pouches nicotine containing pouches, which you can sort of put in your mouth. They also have lozenges and things like that that I much prefer because then you don't get the there was always some I was at the gum taste that kind of gross. It also had a little sugar in it.

It was a little too sweet. And these pouches are mostly flavorless. They have a bit of an aroma. And to be clear, they're not they're not like different shoe, you know, and we'll get into what that difference is. So you're just basically just getting a pretty high dose of nicotine and it's bypassing the liver. So it actually hits you quicker.

Yeah, I've tried the gum and the, and the lozenges and I found with a gum same as you. And also, I think on the instructions that part of it is you chew it a little bit, get a little bit of nicotine out of it, and then you're supposed to park it, which sounds like what you're probably doing with that pouch or what you do with the lozinge.

Because otherwise, I think if you're just chewing it like regular gum and chewing it a lot, it made me nauseous. Yeah. Let's help people understand a little bit why nicotine isn't dangerous. Let's start with that, right? Because as you alluded to at the outset, you would not be blamed for having a knee jerk reaction to the notion that nicotine is a bad thing. So you want to talk for a second Bob about the difference between nicotine and tobacco? Yes.

So, when you're looking at nicotine and tobacco, and you're looking at, well, when you're looking at tobacco, obviously cigarettes contain leaves from tobacco plants. And tobacco also contains nicotine. So you've got that connection there. Something that I didn't realize is that tobacco is actually, it's in a nightshade family of plants. And so when you look at potatoes and tomatoes and eggplants, there's actually, there's nicotine in there, but the level of nicotine and those plants are nowhere near tobacco. So nicotine makes up, it's about one to three percent of the dry weight of tobacco, whereas these nightshades, it's like millions of a percent,

very trace amounts. But interestingly, even the US Surgeon General said there's there's not enough evidence or inadequate evidence to infer a causal relationship between nicotine exposure and risk for cancer. So I think like a lot of other people, so I have you beat Peter by maybe a decade or two as far as my interest in nicotine, but it was more about I smoked in high school a little bit. Smoke cigarettes and I can certainly speak to the addictive nature of cigarettes, but at that time and probably years after that I would just think you know when people would talk about nicotine being bad for you I'd say sure that it's it's in cigarettes and it's probably one of the many carcinogens and tobacco smoke and

cigarettes and it's probably one of the many carcinogens in tobacco smoke. And if you go to, I think it's like the WHO where they've got their long list of potential in known carcinogens. And I think they, it says they have at least 69 chemicals that are contained in tobacco smoke that are carcinogens. But nicotine is actually not one of them. That's an important point, right? This is something really worth reiterating, right? So the US Department of Health and Human Services

says they've identified at least 69 chemicals contained within the tobacco plant, i.e. things that make it into cigarettes that are carcinogens, and nicotine's not one of those things. So it's interesting in that nicotine is the thing that I think we're going to talk about has some benefits. It also unfortunately has that addictive part of it.

So it brings you back to the tobacco, but in and of itself, it doesn't cause cancer. Right. And if you look at the WHO, this could be an entirely different podcast, but red meat and processed meat, processed meat is a, I think it's a class one. And then there's the next class down, which is red meat and processed meat, processed meat is a, I think it's a class one. And then there's the next class down, which is red meat. So I figured I'd go to the list on the WHO. And if there's anything, you know, on nicotine being carcinogenic, I would think that the WHO would have it listed there, but it's, it's not. So I think that's what you're basically saying

is the WHO will go so far as to claim that red meat is a carcinogen, and we've written so much about this topic, and basically said, the evidence suggesting that red meat is carcinogenic is so weak that it's very difficult to take it seriously. And if there's any carcinogenic properties of meat, it's really low signal. And you're saying, if they can't even recognize nicotine as carcinogenic, given their sensitivity for identifying carcinogens, the likelihood that it has any cancer causing properties is approaching epsilon, if not zero. Yeah, that's right. Okay, so where do all these nicotine replacement products come from? Is it safe to say that this entire industry

of gums and patches and lozenges and haylor's nasal sprays, little pouch that I'm sucking on right now, these are basically tools to get people to stop smoking, right? Yeah. So if you, yeah, you look at the literature and there's this, you know, NRT, they call it nicotine replacement therapy. So you've got nicotine, which is addictive. And so you, you could implicate that in getting people to smoke

and stay smoking and make it hard for them to stop. But they're actually exploiting nicotine, in fact, to help people quit smoking. So you've got all these products that some of them, the ones that we'll talk about for the most part, I think, are FDA-approved for nicotine replacement therapy to get people to help quit smoking. And there's some reviews, and probably a lot of people are familiar with the Cochrane collaboration. They put together a review and found high quality evidence that this NRT increases the chances of successfully

quitting smoking by about 50 to 60%. I think anybody who smokes knows how hard it is to quit. But hang on Bob, we're going to have to make sure we make sure people know we're talking relative success increase. Can you put that in absolute terms please? Yes. So the six months, the absolute quit rate, this is just in general, at six months, you try to quit and they look at people after six months and see if they've gone back to smoking

and the people who have quit for six months and haven't returned to smoking, the absolute rate is about 3 to 5 percent, which is pretty depressing. And so in that case, that means that NRT may increase the rate from an absolute perspective by a couple of percentage points, maybe 2 to 3 percent. Yeah, so another great teaching point here, which is you could read the headline and say, wow, nicotine replacement therapy increases your odds of quitting by 50 to 60%. And that sounds like an awfully big number. But you have to always ask the question, what does that mean at an absolute level? And if the absolute rate, the absolute success rate of people quitting tobacco at six months

is two to three percent, and you increase that by 50 to 60 percent. Well, look, it's, you know, it's an improvement, but in the big picture it tells us that it is very hard to quit smoking using NRT, and I got to be honest with you. I don't know why it's not higher, Bob. Like, I don't know why the relative improvement with NRT isn't like a thousand percent or you know like 500 percent. Like why do you have a sense of why? Maybe as a former smoker why when you if you take someone who smokes and you give them an RT you can't get 50 percent absolute quit rate at six months. It's hard for me to say it's been so long since I smoked.

I think it'd be interesting to look into. I wonder if people think they go to a Laws Engine. And the Laws Engine that I've tried and the gum that I've tried, I usually just try the small stokes. So the Laws Engine that I have, I think, are they coming for the most part, 2 milligram and 4 milligram. And I take the 2 milligram one, and I think we'll get to this. But a cigarette supposedly has about one milligram

of nicotine contained within the cigarette, but I think it's a different root of administration, and I think that people might think that it's, they probably say something to the effect of it's just not the same, and they go back to the smoking, and I think some people think it's like, well, maybe it's the oral fixation or things like that.

Or do you think it's just that when you're smoking the inhalation is the fastest route of administration. So the rush and the buzz from the nicotine when you inhale it, you know, across that entire alveolar surface area, nothing can compete with that. And so all of these little PIDLY NRT therapies are just insufficient to reach the same level. I think that plays a role. I think that they're working on, if they haven't already developed this, but patches. And maybe some of the the sprays, the nasal sprays and things like that, that they're part

of why they're, you know, you have these different roots of administration as they're trying to mimic getting a speedier delivery to it. So maybe those will be more efficacious in the future. Well, it'd be interesting actually to at some point do a podcast on smoking cessation because we take this for granted that, gosh, I think at its peak, which would have been about 1964, 1965, I believe up to 59, if not 60% of Americans over the age of 18 smoked cigarettes, which, you know, I don't know how to qualify that. I don't know what constituted smoking, you know, did that include people who just smoked

socially like at a bar, you know, a couple cigarettes a week versus the pack a day smoker. But nevertheless, that's a pretty astonishing quantity. I think the most recent numbers are about 18 to 19% of people over 18. Is that sound about directionally right? Yeah, I think so. I think we'll get to it with COVID that they looked at some prevalence numbers too, because they're comparing rates of hospital admission compared to the general population. And I think it depends, but I think Americans might be like around 13% to 15%. It's definitely gone down. And it reminded me too. I think the podcast with near bars

a lot, he was talking about his centenarians. And talking about is it's genes are the environment. And he would talk about a lot of the centenarians that he was studying and saying that it doesn't look so much like it's environment. And one of his, you know, one of the things that he pointed out was a lot of the centenarians had smoked. And I don't know if that was never smokers.

But if you look at, if you look historically, you would think almost like, how is it possible these people never smoked in their lifetime? It was so prevalent. It was kind of amazing. Yeah. I mean, we haven't had a lot of current smokers enter our practice. A few that have, obviously, that's literally the first thing we address. If you're a smoker and you're interested in longevity, there's harder to find a lower hanging piece of fruit than smoking cessation as you move to improve someone's health. We've used Wellbutrin, which is an

antidepressant. I used to know the numbers. In fact, I think we have a little white paper somewhere in the practice that gave us a bit of an assessment on how to combine NRT with well-butroned, but this might be an interesting topic, but okay, so what can we say about the cognitive benefits of nicotine? So here I am a few minutes after ingesting my little nicotine little patch. It's sitting in here. It's again, it's bypassing my liver. It's getting into my system much quicker because it's being directly absorbed. Maybe it's placebo, but I got to tell you, Bob, I'm feeling pretty sharp right now. I don't want to say I'm just feeling sharp. Yeah. You got a differential equation for me to solve. I'm not offhand, but yeah, I could recite

Stokes theorem like that. I'm ready to go. It's going to go entirely different AMA podcast. You looked into this, so how many studies have tried to ask this question? Direction. Thank you for listening to today's sneak peak AMA episode of The Drive. If you're interested in hearing the complete version of this AMA, you'll want to become a member. We created a membership program to bring you more in-depth exclusive content without relying on paid ads. Membership benefits are many and beyond the complete episodes of the AMA each month, they include the following. Redeculously comprehensive podcast show notes that detail every topic, paper, person, and thing we discuss on each episode of the drive. Access to our private podcast feed. The qualities which were a super short podcast typically less than five minutes released every Tuesday through Friday, which highlight the best questions, topics,

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