00:00:02
- Vaping is actually harder to quit
00:00:05
than cigarette smoking for most people.
00:00:08
Does that mean that cigarette smoking
00:00:10
is fairly easy to quit for most people?
00:00:12
No, 70% of people who smoke cigarettes
00:00:15
report that they would like to quit
00:00:17
if they thought they could.
00:00:19
The success rate of quitting smoking
00:00:21
when people try to go just cold turkey,
00:00:23
just quit with no assistance whatsoever,
00:00:25
they might tell their family and friends,
00:00:26
"Hey, I'm quitting, that's
it," is exceedingly low.
00:00:29
It's 5%.
00:00:31
So 5% of the people that say,
00:00:34
"That's it, I'm not smoking
again despite cancer diagnosis.
00:00:38
I'm not smoking again despite the fear
00:00:40
of the negative health effects.
00:00:41
I'm not going to ever smoke again
00:00:43
despite the financial
cost, the health cost."
00:00:46
I mean, I could list off
a huge number of things
00:00:48
that it does that are negative,
00:00:49
but you already know these
or you've heard them.
00:00:51
You know, makes your skin worse.
00:00:52
It, as I mentioned, it lowers
libido. It disrupts hormones.
00:00:57
It disrupts vascular
function, brain function.
00:01:01
It does all these terrible things
00:01:02
and yet most people who
try and quit simply can't.
00:01:04
And of the 5% that succeed in quitting,
00:01:07
a full 65% of them relapse within a year.
00:01:11
So that's a very depressing picture.
00:01:13
But it's not to say
that people cannot quit
00:01:15
and in fact they can.
00:01:16
There are a couple of methods
00:01:17
that have been shown to help people quit.
00:01:19
Some are behavioral and
some are pharmacologic.
00:01:23
I just want to touch on
the behavioral ones first
00:01:25
because it turns out that
there's a quite powerful method
00:01:29
for quitting nicotine ingestion
by way of cigarette smoking
00:01:33
which also carries over to vaping.
00:01:35
This is beautiful work that's
been done by my colleague,
00:01:37
in fact, close collaborator,
00:01:39
although I was not
involved in the research
00:01:40
that I'm about to describe, at Stanford,
00:01:42
and his name is Dr. David Spiegel.
00:01:44
He is our associate chair of psychiatry.
00:01:47
He's been a guest on the
Huberman Lab podcast.
00:01:49
And he is a world expert,
if not the world expert,
00:01:52
in the clinical applications of hypnosis.
00:01:54
Now, when I say hypnosis,
00:01:55
a lot of people think stage hypnosis,
00:01:57
which is the hypnotist
trying to get people
00:01:59
to do certain things
and say certain things,
00:02:01
not necessarily against their will
00:02:03
because they actually have to agree,
00:02:04
but the hypnotist is dictating
00:02:06
what the person thinks, says, and does.
00:02:09
Clinical hypnosis is
vastly different from that.
00:02:12
Clinical hypnosis is where
the person, the patient,
00:02:15
actually directs their own brain changes
00:02:18
toward a specific emotional
or behavioral goal.
00:02:21
Work from Dr. David Spiegel's
laboratory done in 1993,
00:02:25
but that now has been
repeated many, many times,
00:02:28
has carried over into
some more modern studies
00:02:29
and I will provide links to those studies
00:02:32
in the show note caption so
that you can access them.
00:02:35
Those studies have shown
00:02:36
that using a specific form of hypnosis,
00:02:40
people can achieve complete
and total cessation
00:02:44
of cigarette smoking,
00:02:46
and there's no reason to believe
00:02:47
this doesn't also carry over to vaping,
00:02:49
through one single hypnosis session.
00:02:52
And the success rates are incredibly high
00:02:54
when one considers that normally
00:02:56
it would be only a 5% success rate.
00:02:58
The success rate with
this particular hypnosis
00:03:00
developed at Stanford School of Medicine
00:03:02
by Dr. David Spiegel is 23%
of people who do this hypnosis
00:03:07
one time succeed in quitting smoking.
00:03:10
Now, in the old days, which
actually wasn't that long ago,
00:03:14
before the advent of smartphones
and before the internet
00:03:17
took off to the extent that it has now,
00:03:20
this was done by having
someone come into the clinic
00:03:23
and Dr. Spiegel himself
or one of his colleagues
00:03:25
would take somebody through the hypnosis.
00:03:28
Nowadays, you can access this hypnosis.
00:03:31
There's a wonderful app
00:03:32
that was developed by Dr.
David Spiegel and others.
00:03:35
It's called Reveri, R-E-V-E-R-I.
00:03:38
I've talked about this app a
few times on the podcast before
00:03:40
because there are hypnosis
scripts within the app
00:03:42
for enhancing sleep, for
improving ability to fall asleep
00:03:45
if you wake up in the middle
of the night, for focus,
00:03:47
and a number of other behavioral
and emotional changes.
00:03:51
There's also a function in the Reveri app
00:03:53
for smoking cessation,
00:03:55
which exactly parallels
the sort of in laboratory
00:03:59
and in clinic approaches
that Dr. Spiegel would use
00:04:02
were you to show up at his
clinic or in his laboratory.
00:04:04
And since that's not possible
00:04:06
for the large number of people out there,
00:04:08
if you or somebody else
is trying to quit smoking,
00:04:11
or vaping, or dipping, or
snuffing for that matter,
00:04:15
I strongly encourage you to
check out the Reveri app.
00:04:18
You can find it easily
by going to reveri.com.
00:04:21
It's available in various formats.
00:04:23
Some of it is available free,
00:04:24
some of it is behind a paywall.
00:04:26
But given the tremendously
negative impact of smoking,
00:04:29
vaping, dipping, and snuffing,
00:04:31
the hypnosis for smoking
cessation that Reveri has seems,
00:04:36
at least to me, as a very
powerful and worthwhile resource.
00:04:40
So please check that
out if you're somebody
00:04:41
who's trying to quit ingesting nicotine
00:04:44
by any of the four methods
that I just described.
00:04:47
Now, of course, there are other methods
00:04:48
that people have used to
successfully quit smoking,
00:04:50
or vaping, or other forms
of nicotine delivery.
00:04:53
And there's actually an
excellent review on this topic.
00:04:55
So before diving into
a few of the specifics
00:04:57
about some of the pharmacology
of using nicotine itself
00:05:01
to quit smoking, or nicotine
itself to quit vaping,
00:05:04
or the use of various things,
even SSRIs, antidepressants,
00:05:08
to quit smoking or vaping,
00:05:10
I just want to point
you to a review article
00:05:12
that if you'd like to
get a complete survey
00:05:14
of all the options that are available,
00:05:16
there's an excellent review on this.
00:05:18
It was published just a
couple of years ago in 2020.
00:05:20
The title of the article
00:05:21
is "Pharmacologic Approach
to Smoking Cessation:
00:05:24
An Updated Review for
Daily Clinical Practice."
00:05:27
And even though this is mainly
focused on smoking cessation,
00:05:30
it carries over quite nicely to vaping.
00:05:32
And it details a number of statistics.
00:05:34
You know, the fact that every year
00:05:36
700,000 or more people die
00:05:37
because of smoking related diseases,
00:05:39
so there again, you have
the negative health effects,
00:05:42
that younger people are smoking,
00:05:43
that women are smoking more nowadays,
00:05:45
and that even though you see less smoking
00:05:46
typically in the US and Canada
and even in Northern Europe,
00:05:49
some places there's still
many, many people are smoking
00:05:51
who would like to quit.
00:05:53
But that 75% of people, at
least according to this review,
00:05:56
earlier I said 70%,
00:05:57
but estimates are as high as 75% of people
00:06:00
who try to quit smoking
relapse within the first week.
00:06:03
The first week. They
just go right back to it.
00:06:04
That's how powerfully
reinforcing the nicotine is.
00:06:07
Remember, it's the
nicotine in the cigarette
00:06:09
that's powerfully reinforcing,
00:06:10
but it's also the oral
habit, the motor habit.
00:06:15
You know, there is this thing
00:06:16
about density of sensory
receptors in the lips.
00:06:18
People like bringing things to their lips.
00:06:21
Food, cigarettes, other lips
in some cases, et cetera.
00:06:27
There is a reinforcement
pathway related to that
00:06:29
for sort of obvious adaptive reasons.
00:06:31
And as a consequence,
there is a reinforcement
00:06:35
both from the behavior
and from the dopamine
00:06:38
released from the nicotine itself.
00:06:39
And as I mentioned earlier,
00:06:41
from the positive reinforcement
00:06:43
that comes from increased focus.
00:06:44
So the money that you make through work,
00:06:45
or your attentional ability,
00:06:47
or the fact that you're alert
and people feel you present,
00:06:49
all of that funnels back
into positive reinforcement,
00:06:52
behavioral reinforcement,
00:06:54
and then what we would call addiction.
00:06:56
So this review covers all of
that and then steps beautifully
00:07:00
through nicotine replacement
therapy and various compounds,
00:07:04
several of which I'm
going to talk about now,
00:07:06
which have been shown
to increase that number
00:07:08
that we talked about earlier
00:07:09
of only 5% of people who try
to quit with no other support,
00:07:13
pharmacologic, or hypnosis,
or otherwise just say,
00:07:15
"That's it. I'm not going to smoke again,"
00:07:17
or, "I'm not going to vape again."
00:07:19
Only 5% of people succeed in doing that.
00:07:21
And even among those, many
end up relapsing later,
00:07:24
there are a couple
pharmacologic approaches.
00:07:26
One of the main ones that's
received a lot of attention
00:07:28
in recent years is bupropion,
00:07:30
sometimes referred to by its
commercial name Wellbutrin.
00:07:34
Now, bupropion is a compound
00:07:38
that increases the release of dopamine,
00:07:40
and to a lesser extent epinephrine
00:07:42
and some other neurochemicals as well.
00:07:44
It's used for the treatment of depression
00:07:46
and for smoking cessation.
00:07:48
Now, I want to point out,
again, I'm not a psychiatrist,
00:07:50
so I'm not telling you to take
bupropion, AKA Wellbutrin,
00:07:53
but I'm going to give you a little bit
00:07:55
of the contour of what's typically done
00:07:57
in terms of bupropion administration
00:07:58
to help people get relief
00:08:00
from some of the withdrawal symptoms
00:08:02
of trying to quit smoking, or vaping,
00:08:04
or other forms of nicotine ingestion.
00:08:07
Typically, bupropion is taken
in 300 milligram per day doses
00:08:11
divided into two dosages
of 150 milligrams each
00:08:14
or sometimes there's a
slow release formula.
00:08:17
The dosages will vary
from person to person.
00:08:20
Want to really emphasize
that there is an increased
00:08:23
seizure risk with bupropion.
00:08:25
It only occurs in a small
fraction of the population,
00:08:27
but nonetheless is a real concern
00:08:29
for those members of the population.
00:08:30
So for those of you with seizure risk,
00:08:32
whether you know it or not,
00:08:34
that's going to be a valid concern
00:08:36
in terms of potential side effects.
00:08:38
The other thing about bupropion
00:08:40
is that it has to be used with caution
00:08:42
in patients that have liver
disease or renal disease.
00:08:45
That can impact the amount
that anyone can take.
00:08:47
Meaning sometimes people have
to take a much lower dose
00:08:50
if they have renal
disease or liver disease,
00:08:52
and sometimes they can't take it at all.
00:08:54
Sometimes if people are
taking benzodiazepines
00:08:56
for whatever reason or other sedatives,
00:08:58
there are contraindications there.
00:09:00
So bupropion isn't a, you
know, kind of one size fits all
00:09:03
or magic bullet for quitting smoking.
00:09:05
Nonetheless, for people
that can take it safely,
00:09:08
and again this is a prescription drug,
00:09:10
a board certified psychiatrist
or other physician
00:09:12
is going to have to prescribe it for you
00:09:14
if it's appropriate for you,
00:09:15
and it moves that number
of 5% success rate
00:09:17
to about what one sees
with the clinical hypnosis
00:09:21
to about 20% of people
00:09:23
will successfully overcome their nicotine,
00:09:27
or I should say, their
smoking or vaping addiction.
00:09:30
Now, it's important to ask
why this would work, right?
00:09:33
I mean, it's not as if bupropion
00:09:35
is increasing nicotine per se.
00:09:38
What it's doing is it's tapping
00:09:40
on that mesolimbic reward
pathway increasing dopamine
00:09:42
or at least allowing dopamine levels
00:09:44
to stay substantially elevated enough
00:09:47
that people don't experience
some of the drop in dopamine
00:09:50
that leads to the withdrawal symptoms,
00:09:51
the lessening of mood, et cetera.
00:09:53
And it's no coincidence that bupropion
00:09:55
is also an antidepressant.
00:09:56
It's a common antidepressant for people
00:09:58
that experience negative side effects
00:10:00
with the so-called SSRIs,
00:10:01
the selective serotonin
reuptake inhibitors,
00:10:04
that prevent them from
taking those things,
00:10:05
like lessen libido, or appetite,
00:10:07
or in some cases increased appetite,
00:10:09
or any number of other side
effects that some people,
00:10:12
not all, but some people
experience with SSRIs,
00:10:14
they'll be prescribed Wellbutrin,
00:10:15
bupropion is the generic name.
00:10:18
So Wellbutrin being the
commercial name, again,
00:10:20
bupropion is what they'll
be prescribed instead
00:10:24
with the caveats of seizure
risk, renal disease,
00:10:28
liver disease, et cetera.
00:10:30
The outcomes with Wellbutrin
for smoking cessation
00:10:32
are pretty good.
00:10:33
I mean, if you think about
an increase from 5% to 20%,
00:10:36
that's pretty dramatic.
00:10:37
And yet I also want to refer back
00:10:39
to the incredible success of
the clinical hypnosis approach.
00:10:42
Again, you can find that at reveri.com.
00:10:45
The clinical hypnosis approach
has a success rate of 23%,
00:10:49
so it's very closely aligned
with, if not exceeding,
00:10:52
the success rate with bupropion.
00:10:54
Of course, there are other
pharmacologic approaches
00:10:57
to quitting smoking or vaping.
00:11:00
All of them generally circle back
00:11:01
to increasing dopamine
and/or norepinephrine
00:11:04
in order to offset some
of the withdrawal symptoms
00:11:07
of smoking cessation or vaping cessation.
00:11:10
A very common approach for people
00:11:12
to try and quit smoking or
vaping is to use nicotine itself
00:11:17
to try and prevent people
from seeking nicotine
00:11:20
through a cigarette or a vape pen.
00:11:22
What I mean by that is people
using a nicotine patch,
00:11:25
or nicotine gum, or other
nicotine delivery device
00:11:29
that is not cigarettes and not
vaping in order to maintain
00:11:34
levels of nicotine in their bloodstream,
00:11:37
which of course means
maintain levels of nicotine
00:11:39
in their brain and body,
00:11:41
to the same extent that they would
00:11:43
if they were smoking or vaping.
00:11:45
Maybe even gradually taking down
00:11:48
the total amount of nicotine
in their brain and body
00:11:50
by reducing the number or
size of nicotine gum pieces
00:11:55
that they ingest each day,
00:11:56
or keeping the patch on for
a shorter amount of time,
00:11:59
or getting a lower dose patch
00:12:00
that releases less nicotine
total or over time.
00:12:05
All of those approaches have been shown
00:12:07
to be reasonably successful,
00:12:09
get to the numbers in a few minutes,
00:12:10
but reasonably successful
in allowing people
00:12:13
to quit smoking or vaping.
00:12:17
Again, most of the data
is on cigarette smoking
00:12:20
because vaping is a
relatively new phenomenon,
00:12:22
although quite troublingly
00:12:24
it's a very rapidly increasing behavior,
00:12:28
especially in the young population.
00:12:29
So that's why I'm kind of
lumping these two things together
00:12:31
because I think very
soon we are going to need
00:12:35
an all out campaign for how
to counter vaping addiction.
00:12:40
So what do we know about smoking cessation
00:12:42
using nicotine itself?
00:12:44
Is the patch best? Is nicotine gum best?
00:12:47
Turns out that a combination
of approaches is best.
00:12:51
So somewhat surprising,
00:12:52
but it is very clear from the literature
00:12:53
that I was able to find,
00:12:54
that using nicotine patches
for some period of time
00:12:57
and then switching to a gum
00:12:59
and then perhaps switching
to a nasal spray,
00:13:03
that's going to be the most effective.
00:13:05
Then the question is how long
to continue each of those
00:13:08
and whether or not to overlap them.
00:13:10
It seems as if doing one for about a week,
00:13:12
and then switching to
another for about a week,
00:13:14
and then switching to another
00:13:15
is one rationable and reasonable approach
00:13:18
that many people have used successfully.
00:13:20
Why would that be?
00:13:21
Well, it all has to do
with the different rates
00:13:23
of absorption of nicotine
into the bloodstream
00:13:26
and then the downstream
consequences of that
00:13:28
on the dopamine,
acetylcholine, epinephrine,
00:13:30
and other systems of the brain and body.
00:13:33
And while there hasn't been
an extremely detailed study
00:13:36
of the exact kinetics of, you
know, how the nasal sprays,
00:13:39
versus the transdermal
patches, versus the gums,
00:13:41
et cetera, work, there's
a logical structure to it
00:13:44
that will immediately make sense to you.
00:13:45
First of all, the transdermal patches
00:13:47
provide a fairly steady
state dopamine release
00:13:50
across the day and oftentimes
00:13:52
people are wearing them at night as well.
00:13:54
This is relevant because if
people are ingesting nicotine
00:13:57
by way of smoking and vaping, you know,
00:14:00
hopefully they're not waking
up in the middle of the night
00:14:02
just to smoke or vape,
00:14:03
or believe it or not, some people do that,
00:14:04
but of course, while people are asleep
00:14:06
they are not smoking or vaping.
00:14:09
They always tell you don't fall asleep
00:14:09
with a cigarette in your mouth.
00:14:10
You'd burn the whole house down.
00:14:12
But exceedingly rare to have people
00:14:15
who are smoking in their sleep.
00:14:17
So people wake up in the morning
00:14:19
and because the half-life of nicotine
00:14:21
from smoking or vaping is very short,
00:14:22
anywhere from one to two hours,
00:14:24
they're essentially in
a state of withdrawal
00:14:26
at the point where they
wake up in the morning.
00:14:27
How can I say that?
00:14:28
Well, remember, withdrawal
sets in about four hours
00:14:30
after the last ingestion
of nicotine by cigarette
00:14:33
or by inhalation from a vape pen.
00:14:35
So people are waking up
in nicotine withdrawal
00:14:38
and then immediately
going into the behavior
00:14:40
of ingesting nicotine
00:14:41
or very soon after waking for most people.
00:14:44
So nicotine patch is
going to be very effective
00:14:47
for a week or so.
00:14:48
Again, talk to your physician
00:14:49
about the best approach for this.
00:14:50
But then switching to a nasal spray
00:14:54
or switching to nicotine
gum for about a week,
00:14:56
which is going to change the kinetics
00:14:58
of that nicotine absorption
into the bloodstream
00:15:00
and change the release of dopamine
00:15:02
and other neurochemicals within the brain.
00:15:04
That's going to keep the system
intentionally off balance
00:15:07
so that it never comes to
expect one single pattern
00:15:11
or amplitude of dopamine release.
00:15:14
And that is a very powerful way for a,
00:15:19
let's just call it a
quitting method, to work
00:15:22
because as I've always said,
00:15:23
the most powerful schedule of dopamine
00:15:26
is going to be this random
intermittent reward.
00:15:29
This is what's used in the casinos
00:15:31
in order to take your money,
and generally they do.
00:15:33
On average, they take your
money more than you take theirs,
00:15:36
and they take more of
it, not just more often,
00:15:39
because they use this random
intermittent schedule.
00:15:42
The random intermittent schedule
00:15:43
is one in which you don't really know
00:15:45
when the peaks in dopamine
are going to arrive
00:15:47
and so there isn't this
expectation in craving,
00:15:50
and then all of a sudden
when dopamine is released
00:15:51
it's extremely high.
00:15:52
That's how they get
you to continue playing
00:15:54
even though basically you're losing money
00:15:55
and your dopamine is dropping.
00:15:56
They elevate it every once in a while.
00:15:59
Nicotine replacement can
be used in a similar way,
00:16:02
but in a benevolent way
in order to help you
00:16:04
get over smoking or vaping
00:16:06
by keeping the total
amounts of dopamine variable
00:16:09
around the clock.
00:16:11
And by changing the amount
of dopamine that's released,
00:16:14
it seems to help people
behaviorally and psychologically
00:16:17
because they don't come to expect
00:16:18
having a particular amount of dopamine
00:16:20
in their brain and
blood at any given time.
00:16:22
[upbeat music]
