It took decades, with Big Tobacco fighting a determined but doomed rear-guard action, for health authorities and the public to be awakened to the harms of smoking; it pretty much increases the risk of acquiring every imaginable human affliction. The cigarette ship has long since sailed.
Lately, other forms of “smokeless tobacco” have been touted as preferable alternatives to cigarettes. Nicotine patches, pouches, gums, and vapes are considered safer substitutes, offering an off-ramp or harm reduction to the addicted. While recommended to aid smoking cessation only short-term, they are used on an ongoing basis by many Americans.
Barack Obama was famously outed for chomping on Nicorette gum, presumably long after quitting cigarettes; RFK Jr. has fessed up to using nicotine pouches and endorses them as an alternative to smoking. Many anti-aging influencers tout the benefits of “therapeutic” nicotine dosing.
Lately, a campaign has been launched against nicotine alternatives. My home state of New York has bought TV ads and subway billboards announcing: “Know the Risks: Nicotine is Not Safe for Teens”.
Indeed, vaping has been associated with “popcorn lung”—you don’t have to be a Latin scholar to recognize that its medical name, bronchiolitis obliterans, is bad news. Inhaling hot gases mixed with chemical solvents and flavorings takes a toll on delicate lung tissue. Flavors like cotton candy, bubble gum, pink lemonade, or other sweet and fruity flavors circumvent the harsh taste of tobacco from cigarettes, and make vaping seem fun.
And vaping is especially popular among kids because it’s cheaper than cigarettes, readily available, and can be consumed more surreptitiously. As a vehicle for addictive nicotine, it turns youth into lifelong customers.
But the thrust of the New York campaign—echoed internationally—is that nicotine per se is harmful:
“Vaping nicotine can also mess with how you feel. The cravings can cause mood swings, and the next hit might make you feel good for a bit, but then you could feel really low. Nicotine makes it harder to pay attention, makes you feel off, and more anxious or sad. You might want to reach for your vape to ‘feel better’, but it only makes things worse.”
The TV ad shows a scowling teenager running off from his concerned parents, presumably to get his next vape “fix”. The ad claims that nicotine can cause “Sadness, depression, relationship issues, difficulty focusing, loss of interest in things you used to enjoy, panic attacks, fast heartbeat, irritability, and anxiety”. “Nicotine = Brain Poison”, it concludes ominously.
Indeed, when I smoked in my 20s, I felt it reinforced my anxiety, but not because it inherently affected my emotions. Rather, I smoked to relieve anxiety, which as a 20-something I had plenty of. And, guilty over smoking, I rationalized that tobacco helped me cope—and thus I set in motion an excuse for reaching for the solace of nicotine. It’s no accident that a movie cliché has been the ceremonial offering of a final cigarette to the hapless firing squad victim.
Long after I stopped smoking, I’ve often morbidly joked that, should I ever be on my way to the execution yard, I’d readily accept that offer of a few last puffs.
What I got wrong was that the discomfort of withdrawal—that comes minutes or hours after your last dose of nicotine—became the catalyst for anxiety, which in turn offered permission for another “calming” cigarette. So, reliably, I gifted myself 10 to 15 bouts of anxiety every day. It was truly Pavlovian!
Now, off cigarettes, I have considerably fewer episodes of anxiety.
But it’s one thing to conflate the concrete harms of vaping, and the impact of hooking millions of adolescent brains during their formative years, with the known salutary effects of nicotine.
Yes, salutary!
For example, last week, the Wall Street Journal heralded: “Tech Startups Are Handing Out Free Nicotine Pouches to Boost Productivity”. So, what gives?
First, let’s examine the science behind nicotine’s circulatory and brain effects. Nicotine is a known vasoconstrictor—it causes blood vessels to clamp down. This makes it theoretically inadvisable for people who have heart disease, poorly controlled high blood pressure, diabetic circulatory problems, or Raynaud’s, which causes painful white fingertips in the cold.
It also suggests that you shouldn’t use nicotine pre-workout, because it may compromise blood flow to muscles.
Nicotine can accelerate heart rate. But whether this is consequential is unknown—especially in view of the fact that another popular pulse quickener and vasoconstrictor—caffeine—has been mostly exonerated of adverse heart effects.
European health authorities have lately taken a really hard line against even non-inhaled forms of nicotine like pouches, citing their inherent cardiovascular risks:
“Nicotine-containing products, whether combustible or smokeless, pose a growing threat to cardiovascular (CV) health . . . The vascular endothelium serves as a gatekeeper for CV health. It regulates blood flow, inflammation, platelet activity, and vascular tone. When it becomes dysfunctional, characterized by reduced NO [nitric oxide] bioavailability and increased ROS [reactive oxygen species], it sets the stage for atherosclerosis, thrombosis, and ultimately MACE [major adverse cardiac events]. Nicotine, regardless of its delivery system, has been shown to impair endothelial function consistently and rapidly. This makes endothelial dysfunction an ideal early biomarker of nicotine-induced vascular damage, a scientific insight with direct policy relevance.”
Hence, in a regulatory turning point last year, the European Commission enacted harsh excise duties on smokeless nicotine products, including pouches (unlike chewing tobacco, nicotine pouches have not been shown to increase the risk of mouth, tongue, or throat cancer).
Despite the regulators’ confidence, many meta-analyses find no increased risk for major cardiovascular events (heart attack, stroke, death) for cigarette quitters using nicotine substitutes compared to non-nicotine quitters.
There are worse things you can do for your cardiovascular system: smoke pot, slam hyper-caffeinated energy drinks, overuse NSAIDS, or eat ultra-processed foods.
So what of claims of the benefits of nicotine? It turns out they are robust.
• Depression: A small open-label study showed that nicotine patches were effective in alleviating late-life depression. The authors reported:
“And we were pleasantly surprised with the results. We found an over 86% response to nicotine in our small sample and an over 50% remission rate. This is comparable if not better than open-label trials for currently available antidepressants.“
The benefits may stem from nicotine’s ability to enhance levels of dopamine, a neurotransmitter associated with motivation and reward. But, as with other dopamine-enhancing agents like cocaine, this boosts nicotine’s addictive potential.
• Cognitive performance: Nicotine acts strongly on acetylcholine receptors in the brain—a target for the drugs that ameliorate the symptoms of Alzheimer’s. A study (“Nicotine treatment of mild cognitive impairment”) demonstrated that nicotine patches “improve primary and secondary cognitive measures of attention, memory, and mental processing.” Hence claims that nicotine can boost productivity.
• Parkinson’s Disease: Not only does nicotine deliver a shot of dopamine—mimicking current pharmaceutical treatments for Parkinson’s—it also seems to help protect dopaminergic neurons, whose degeneration is thought to underlie severe movement disorders. Studies have found that nicotine users—and even cigarette smokers—are somewhat shielded from susceptibility to Parkinson’s.
• Schizophrenia: Anyone who’s visited a psych ward—as I have during my medical training—would be impressed by the degree to which schizophrenic patients resort to cigarettes; they smoke up to three times more than the general population. There’s a reason for that: nicotine amps up beneficial neurotransmitters in the brain, helping schizophrenics cope with negative symptoms. A recent study found that, “male smokers showed greater improvement in negative symptoms than male nonsmokers after 12 weeks of treatment with antipsychotics.”
• Inflammatory Disorders: Anecdotal evidence claims that ulcerative colitis sufferers obtain relief by smoking or using nicotine patches. A recent review confirmed:
“According to the data analysis from recent studies in the past 20 years, nicotine exerts much more anti-inflammatory effects than pro-inflammatory ones, especially in ulcerative colitis, arthritis, sepsis, and endotoxemia.”
Another study has suggested, “Our results add evidence to the hypothesis that nicotine exerts anti-inflammatory and immune-modulating effects in a way that might decrease the risk of developing MS.”
• Anti-aging: Research suggests that nicotine has profound effects on many aging pathways, including by ameliorating “inflamm-aging”, countering free radicals, supporting mitochondrial function, and encouraging cellular resistance to toxic insults. Nicotine was even found to raise levels of the energetic compound NAD+, and improve age-related symptoms, in mice.
BOTTOMLINE: It may be that nicotine, like much of nature’s pharmacopeia (think caffeine), has a positive role to play, but only if applied judiciously. It should neither be subject to draconian Prohibition, nor should it be casually dispensed as a panacea.
There’s something to deplore about hooking an entire generation of young people on amped-up nicotine delivery systems, like vapes, with unknown consequences on developing brains, while guaranteeing lifelong addiction.
But for certain neurodegenerative conditions, age-related debility, some psychiatric conditions, or for long-term use to avoid smoking relapse, nicotine’s benefits may outweigh its downsides.
