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Rethinking nicotine: illusions, delusions and some conclusions
The document discusses the multifaceted use of nicotine, highlighting its psychoactive effects, potential cognitive enhancements, and implications for addiction. It questions traditional views on harm associated with nicotine, especially in light of reduced-risk delivery systems like vaping, and explores the motivations behind youth vaping. Ultimately, it suggests a need to rethink nicotine's role in public health and its perception as a recreational stimulant without significant harm.
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Rethinking nicotine: illusions, delusions and some conclusions
- 1. Rethinking nicotine Illusions, delusions,and a few conclusions Clive Bates Counterfactual E-cigarette Summit UK London 9 December 2022 (Full version, updated with annotations)
- 2. 1. People likenicotine
- 3. Nicotine acts on nicotiniccholinergic receptors, triggering the release of dopamine, producing rewarding psychoactive effects.
- 4. Nicotine acts on nicotiniccholinergic receptors, triggering the release of dopamine producing rewarding psychoactive effects.
- 5. Why do peopleuse nicotine? Mood control In humans, nicotine from tobacco induces stimulation and pleasure, and reduces stress and anxiety. Smokers come to use nicotine to modulate their level of arousal and for mood control in daily life.
- 6. Why do peopleuse nicotine? Mood control In humans, nicotine from tobacco induces stimulation and pleasure, and reduces stress and anxiety. Smokers come to use nicotine to modulate their level of arousal and for mood control in daily life.
- 7. Why do peopleuse nicotine? Cognitive enhancement Cognitive improvement is one of the best-established therapeutic effects of nicotinic stimulation. Nicotine improves performance on attentionally and cognitively demanding vigilance tasks and response inhibition performance, suggesting that nicotine may act to optimize attention/response mechanisms as well as enhancing working memory in humans.
- 8. Why do peopleuse nicotine? Cognitive enhancement Cognitive improvement is one of the best-established therapeutic effects of nicotinic stimulation. Nicotine improves performance on attentionally and cognitively demanding vigilance tasks and response inhibition performance, suggesting that nicotine may act to optimize attention/response mechanisms as well as enhancing working memory in humans.
- 9. Why do peopleuse nicotine? Regulation: Attention deficit disorder Non-smoking young adults with ADHD-C showed improvements in cognitive performance following nicotine administration in several domains that are central to ADHD.
- 10. Why do peopleuse nicotine? Regulation: Attention deficit disorder Non-smoking young adults with ADHD-C showed improvements in cognitive performance following nicotine administration in several domains that are central to ADHD.
- 11. Why do peopleuse nicotine? Regulation: Psychosis …nicotine may represent a therapeutic strategy for the treatment of schizophrenia, and a physiological basis for the tendency of patients with schizophrenia to self-medicate by smoking
- 12. Why do peopleuse nicotine? Regulation: Psychosis …nicotine may represent a therapeutic strategy for the treatment of schizophrenia, and a physiological basis for the tendency of patients with schizophrenia to self-medicate by smoking Also, Parkinson’s, dementia, weight control, athletic performance…. A significant literature
- 14. What if nicotinehas functional benefits and hedonistic appeal for some people?
- 15. 2. The disappearingdeterrent
- 16. Harm is thecurrency of tobacco control
- 17. Smoking related harmsare the most important deterrent to nicotine use
- 18. But harms areassociated with the delivery system, not the drug “People smoke for the nicotine but die from the tar”. Professor Michael Russell 1932-2009 Russell MJ. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ 1976;1:1430–3
- 19. Smokeless tobacco Tobacco based Purenicotine based Heated aerosol Unheated Items are not shown to scale Oral nicotine products Vaping products Heated tobacco products “Heat-not-burn”
- 20. Much lower Much lower Much lower Much lower Much lower Much lower The strongest evidencefor deeply reduced harm is reduced exposure 20 Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, Carcinogen, and Toxin Exposure in Long- Term E-Cigarette and Nicotine Replacement Therapy Users. Ann Intern Med 2017
- 21. 1,400-page assessment concludesvery low risks compared to smoking 21 McNeill, A, Simonavičius, E, Brose, LS, Taylor, E, East, K, Zuikova, E, Calder, R and Robson, D (2022). Nicotine vaping in England: an evidence update including health risks and perceptions, September 2022. A report commissioned by the Office for Health Improvement and Disparities. London: Office for “…vaping poses only a small fraction of the risks of smoking”
- 22. Why do peoplequit? Gallus S, Muttarak R, Franchi M, et al. Why do smokers quit? Eur J Cancer Prev 2013;22(1):96–101.
- 23. People quit toavoid harm Gallus S, Muttarak R, Franchi M, et al. Why do smokers quit? Eur J Cancer Prev 2013;22(1):96–101.
- 24. Main justification fortobacco control policies is to address harm
- 25. What happens tothe deterrent if there is minimal harm associated with nicotine use?
- 26. 3. Is nicotineaddictive?
- 27. Definitions of “Addiction” Addictionis marked by a change in behavior caused by the biochemical changes in the brain after continued substance abuse. Substance use becomes the main priority of the addict, regardless of the harm they may cause to themselves or others. Addiction Center A compulsive, chronic, physiological or psychological need for a habit-forming substance, behavior, or activity having harmful physical, psychological, or social effects Meriam Webster Dictionary Addiction is a complex condition, a brain disease that is manifested by compulsive substance use despite harmful consequence. People with addiction (severe substance use disorder) have an intense focus on using a certain substance(s), such as alcohol or drugs, to the point that it takes over their life. American Psychiatric Association Addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. National Institute on Drug Abuse (NIDA)
- 28. Definitions of “Addiction” Addictionis marked by a change in behavior caused by the biochemical changes in the brain after continued substance abuse. Substance use becomes the main priority of the addict, regardless of the harm they may cause to themselves or others. Addiction Center A compulsive, chronic, physiological or psychological need for a habit-forming substance, behavior, or activity having harmful physical, psychological, or social effects Meriam Webster Dictionary Addiction is a complex condition, a brain disease that is manifested by compulsive substance use despite harmful consequence. People with addiction (severe substance use disorder) have an intense focus on using a certain substance(s), such as alcohol or drugs, to the point that it takes over their life. American Psychiatric Association Addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. National Institute on Drug Abuse (NIDA)
- 29. Formal addiction ontology:Addiction A mental disposition towards repeated episodes of abnormally high levels of motivation to engage in a behaviour, acquired as a result of engaging in the behaviour, where the behaviour results in risk or occurrence of serious net harm.
- 30. Formal addiction ontology:Addiction This entity focuses on abnormal motivation to engage in a behaviour and includes serious net harm as a feature. The reason is to limit the class to things that merit a treatment and public health response.
- 31. Formal addiction ontology:Dependence A bodily disposition which is realised as impaired functioning following reduction or termination of use of a psychoactive substance..
- 32.
- 33. Socially acceptable psychoactivesubstances
- 34. Nicotine as arecreational drug There is no compelling objection to the recreational and even addictive use of nicotine provided it is not shown to be physically, psychologically, or socially harmful to the user or to others. The Lancet, 1991 Professor Michael Russell 1932-2009 Russell, M. A. H. (1991). Nicotine use after the year 2000. The Lancet, 337(8751), 1191–1192.
- 35. When delivered with minimalharm, should nicotine just be regarded as a socially acceptable recreational stimulant?
- 36. 4. Adolescents andnicotine
- 37. Youth vaping –United States
- 38. Youth vaping –two distinct behaviours Frequent vaping Mostly experimental, or frivolous use More committed use
- 39. Youth vaping comesin two forms: frivolous experimentation and displacement of smoking
- 40. Nicotine: only forformer smokers? “Vaping is very unlikely to be risk-free. So we strongly discourage anyone who has never smoked from taking up vaping or smoking.” “ENDS are not risk free. And they contain nicotine. So, any use of e- cigarettes by a kid is bad for public health.” Ann McNeill Professor of Addictions King’s College London Mitch Zeller Former Director Center for Tobacco Products, FDA Realistic? Should people who want to use nicotine have to smoke first? Realistic? Adolescents will ALWAYS do what adults do
- 41. 0 5 10 15 20 25 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Norway: daily tobaccouse women age 16-24 - per cent Should prior smoking be a prerequisite for nicotine use? 1 percent 17 percent Snus Cigarettes
- 42. Adolescents will usenicotine as long as adults do
- 43. Adolescents will usenicotine as long as adults do
- 44. Youth substance usejust is a thing
- 45. A declining trendin US adolescent nicotine use
- 46. A declining trendin US adolescent nicotine use
- 48. Should we careless about youth vaping and focus more on more serious risks to young people?
- 49. 5. New conceptualframing
- 50. Long term alternativesto tobacco / smoking It is not so much the efficacy of new nicotine delivery systems as temporary aids to cessation… Professor Michael Russell 1932-2009 Russell, M. A. H. (1991). The future of nicotine replacement. British Journal of Addiction, 86(5), 653–658. ...but their potential as long-term alternatives to tobacco that makes the virtual elimination of tobacco a realistic future target.
- 51. Three overlapping epochs Rethinkingnicotine 2020 - 2040 3 Tobacco harm reduction 2000 - 2030 2 Tobacco control 1960 - 2010 1 How do we stop tobacco use and fight Big Tobacco? How do we reduce harms caused by smoking? How do we manage nicotine as a socially acceptable stimulant?
- 53. How do weapproach nicotine once we have reached “smoke-free” (happening by generations already)?
- 54. 6. Who isthreatened by nicotine without harm?
- 58. The tobacco controlestablishment is threatened Three strategies are evident 1. Disinformation about harm 2. Shifting focus to nicotine 3. Non-health objectives
- 59. 1. Fake newsabout health impacts “These products are falsely marketed as safer and more sustainable options to deadly cigarettes, misleading consumers, media and international institutions.”
- 60. 1. Fake newsabout health impacts “…over 40 organizations and professors from all continents”. 10 November 2021 “These products are falsely marketed as safer and more sustainable options to deadly cigarettes, misleading consumers, media and international institutions.”
- 61. 1. Fake newsabout health impacts
- 62. ASH Finland isa national public health organisation and a tobacco policy expert. We promote to end the use of tobacco and other nicotine products as well as intoxicant-free lifestyle. 2. Shifting goals to nicotine ASH Finland
- 63. ASH Finland isa national public health organisation and a tobacco policy expert. We promote to end the use of tobacco and other nicotine products as well as intoxicant-free lifestyle. 2. Shifting goals to nicotine ASH Finland
- 64. 3. Emphasis onnon-health objectives
- 65. The tobacco controlcommunity finds it… “…difficult to accept that availability of snus may have greater impacts in reducing smoking than the regulations we have spent a lifetime fighting for.” Karl Erik Lund
- 66. Tobacco control existsto address harms and fight industry malpractice? What when or if there is little of either?
- 67.
Editor's Notes
- #4 We somtimes forget that people smoke for a reason, and whether it is the functional effect of the drug or ‘addiction’ and relief from withdrawal or a bit of each, it hardly matter if you smoke– if you are a smoker these things matter to you. N Engl J Med. 2010 June 17; 362(24): 2295–2303. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928221/
- #5 We somtimes forget that people smoke for a reason, and whether it is the functional effect of the drug or ‘addiction’ and relief from withdrawal or a bit of each, it hardly matter if you smoke– if you are a smoker these things matter to you. N Engl J Med. 2010 June 17; 362(24): 2295–2303. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928221/
- #10 We somtimes forget that people smoke for a reason, and whether it is the functional effect of the drug or ‘addiction’ and relief from withdrawal or a bit of each, it hardly matter if you smoke– if you are a smoker these things matter to you. Neal Benowitz describes the nicotine reward and reinforcement system – this is an extract from his paper N Engl J Med. 2010 June 17; 362(24): 2295–2303. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928221/
- #11 We somtimes forget that people smoke for a reason, and whether it is the functional effect of the drug or ‘addiction’ and relief from withdrawal or a bit of each, it hardly matter if you smoke– if you are a smoker these things matter to you. Neal Benowitz describes the nicotine reward and reinforcement system – this is an extract from his paper N Engl J Med. 2010 June 17; 362(24): 2295–2303. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928221/
- #12 We somtimes forget that people smoke for a reason, and whether it is the functional effect of the drug or ‘addiction’ and relief from withdrawal or a bit of each, it hardly matter if you smoke– if you are a smoker these things matter to you. Neal Benowitz describes the nicotine reward and reinforcement system – this is an extract from his paper N Engl J Med. 2010 June 17; 362(24): 2295–2303. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928221/
- #13 We somtimes forget that people smoke for a reason, and whether it is the functional effect of the drug or ‘addiction’ and relief from withdrawal or a bit of each, it hardly matter if you smoke– if you are a smoker these things matter to you. Neal Benowitz describes the nicotine reward and reinforcement system – this is an extract from his paper N Engl J Med. 2010 June 17; 362(24): 2295–2303. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928221/
- #20 Vaping products Top row shows: 1st generation cig-a-likes 2nd generation ego or ‘pen’ type devices 3rd generation tanks / mods type Bottom row shows Large electronic hookah Small shisha pipes Electronic pipe … there are many other configurations Heated tobacco products – sometimes referred to as heat-not-burn to distinguish between combustible products Shows the iQOs, Ploom and Glo products Novel nicotine products - shows Nicoccino – a nicotine containing film Zonnic – a range of nicotine products – lozenges, gum etc Voke – a cold aerosol (approved but not marketed) Niorette – cross-over NRT Smokeless tobacco Snus Moist snuff Tobacco-based lozenge