How to Quit Smoking, Vaping or Dipping Tobacco

00:00:00.000 | [Silence]

00:00:02.960 | Vaping is actually harder to quit

00:00:05.360 | than cigarette smoking for most people.

00:00:08.440 | Now, does that mean that cigarette smoking

00:00:10.080 | is fairly easy to quit for most people?

00:00:12.460 | No, 70% of people who smoke cigarettes

00:00:15.600 | report that they would like to quit

00:00:17.080 | if they thought they could.

00:00:19.400 | The success rate of quitting smoking

00:00:21.660 | when people try to go just cold turkey,

00:00:23.680 | just quit with no assistance whatsoever,

00:00:25.440 | they might tell their family and friends,

00:00:26.720 | "Hey, I'm quitting, that's it," is exceedingly low.

00:00:29.920 | It's 5%.

00:00:31.920 | So 5% of the people that say, "That's it,

00:00:35.360 | I'm not smoking again, despite cancer diagnosis,

00:00:38.760 | I'm not smoking again,

00:00:39.600 | despite the fear of the negative health effects,

00:00:41.200 | I'm not going to ever smoke again,

00:00:43.200 | despite the financial cost, the health cost."

00:00:46.600 | I mean, I could list off a huge number of things

00:00:48.780 | that it does that are negative,

00:00:49.640 | but you already know these or you've heard them.

00:00:51.560 | It makes your skin worse.

00:00:53.520 | As I mentioned, it lowers libido, it disrupts hormones,

00:00:57.400 | it disrupts vascular function, brain function,

00:01:01.160 | it does all these terrible things.

00:01:02.360 | And yet most people who try and quit simply can't.

00:01:04.800 | And of the 5% that succeed in quitting,

00:01:07.480 | a full 65% of them relapse within a year.

00:01:11.080 | So that's a very depressing picture,

00:01:13.400 | but it's not to say that people cannot quit.

00:01:15.560 | In fact, they can.

00:01:16.480 | There are a couple of methods

00:01:17.520 | that have been shown to help people quit.

00:01:19.960 | Some are behavioral and some are pharmacologic.

00:01:23.600 | I just want to touch on the behavioral ones first,

00:01:25.940 | because it turns out that there's a quite powerful method

00:01:29.360 | for quitting nicotine ingestion by way of cigarette smoking,

00:01:33.280 | which also carries over to vaping.

00:01:35.280 | This is beautiful work that's been done by my colleague,

00:01:38.040 | in fact, close collaborator,

00:01:39.280 | although I was not involved in the research

00:01:40.760 | that I'm about to describe, at Stanford.

00:01:42.700 | And his name is Dr. David Spiegel.

00:01:44.920 | He is our Associate Chair of Psychiatry.

00:01:47.100 | He's been a guest on the Huberman Lab Podcast,

00:01:49.320 | and he is a world expert, if not the world expert,

00:01:52.340 | in the clinical applications of hypnosis.

00:01:54.680 | Now, when I say hypnosis,

00:01:55.800 | a lot of people think stage hypnosis,

00:01:57.520 | which is the hypnotist trying to get people

00:01:59.080 | to do certain things and say certain things,

00:02:01.460 | not necessarily against their will,

00:02:03.460 | because they actually have to agree,

00:02:04.680 | but the hypnotist is dictating

00:02:06.540 | what the person thinks, says, and does.

00:02:09.400 | Clinical hypnosis is vastly different from that.

00:02:12.400 | Clinical hypnosis is where the person, the patient,

00:02:15.520 | actually directs their own brain changes

00:02:18.440 | toward a specific emotional or behavioral goal.

00:02:21.680 | Work from Dr. David Spiegel's laboratory, done in 1993,

00:02:25.880 | but that now has been repeated many, many times,

00:02:28.160 | and it's carried over into some more modern studies,

00:02:30.000 | and I'll provide links to those studies

00:02:32.460 | in the show note caption so that you can access them.

00:02:35.280 | Those studies have shown

00:02:36.540 | that using a specific form of hypnosis,

00:02:39.440 | people can achieve complete and total cessation

00:02:44.480 | of cigarette smoking,

00:02:46.240 | and there's no reason to believe

00:02:47.300 | this doesn't also carry over to vaping,

00:02:49.620 | through one single hypnosis session,

00:02:52.300 | and the success rates are incredibly high

00:02:54.920 | when one considers that normally

00:02:56.340 | it would be only a 5% success rate.

00:02:58.820 | The success rate with this particular hypnosis

00:03:00.980 | developed at Stanford School of Medicine

00:03:02.820 | by Dr. David Spiegel is 23% of people

00:03:06.460 | who do this hypnosis one time succeed in quitting smoking.

00:03:10.140 | Now, in the old days, which actually wasn't that long ago,

00:03:14.140 | before the advent of smartphones

00:03:16.240 | and before the internet took off

00:03:18.280 | to the extent that it has now,

00:03:19.900 | this was done by having someone come into the clinic

00:03:23.260 | and Dr. Spiegel himself or one of his colleagues

00:03:25.860 | would take somebody through the hypnosis.

00:03:27.900 | Nowadays, you can access this hypnosis.

00:03:31.120 | There's a wonderful app

00:03:32.700 | that was developed by Dr. David Spiegel and others.

00:03:35.780 | It's called Reveri, R-E-V-E-R-I.

00:03:38.360 | I've talked about this app a few times on the podcast before

00:03:40.540 | because there are hypnosis scripts within the app

00:03:42.820 | for enhancing sleep, for improving ability to fall asleep

00:03:45.420 | if you wake up in the middle of the night,

00:03:47.020 | for focus and a number of other behavioral

00:03:49.260 | and emotional changes.

00:03:51.060 | There's also a function in the Reveri app

00:03:53.540 | for smoking cessation, which exactly parallels

00:03:57.460 | the sort of in-laboratory and in-clinic approaches

00:04:01.280 | that Dr. Spiegel would use

00:04:02.500 | were you to show up at his clinic or his laboratory.

00:04:04.980 | And since that's not possible

00:04:06.460 | for the large number of people out there,

00:04:08.420 | if you or somebody else is trying to quit smoking

00:04:11.260 | or vaping or dipping or snuffing for that matter,

00:04:15.680 | I strongly encourage you to check out the Reveri app.

00:04:18.380 | You can find it easily by going to reveri.com.

00:04:21.320 | It's available in various formats.

00:04:23.200 | Some of it is available free, some of it is behind a paywall

00:04:26.120 | but given the tremendously negative impact

00:04:28.440 | of smoking, vaping, dipping and snuffing,

00:04:31.800 | the hypnosis for smoking cessation that Reveri has

00:04:35.920 | seems at least to me as a very powerful

00:04:39.080 | and worthwhile resource.

00:04:40.120 | So please check that out if you're somebody

00:04:41.600 | who's trying to quit ingesting nicotine

00:04:44.400 | by any of the four methods that I just described.

00:04:47.160 | Now, of course, there are other methods

00:04:48.320 | that people have used to successfully quit smoking

00:04:50.280 | or vaping or other forms of nicotine delivery.

00:04:53.520 | And there's actually an excellent review on this topic.

00:04:55.920 | So before diving into a few of the specifics

00:04:57.800 | about some of the pharmacology of using nicotine itself

00:05:01.760 | to quit smoking or nicotine itself to quit vaping

00:05:04.600 | or the use of various things, even SSRIs, antidepressants

00:05:08.640 | to quit smoking or vaping,

00:05:10.880 | I just want to point you to a review article

00:05:12.640 | that if you'd like to get a complete survey

00:05:14.240 | of all the options that are available,

00:05:16.160 | there's an excellent review on this.

00:05:18.240 | It was published just a couple of years ago in 2020.

00:05:20.720 | The title of the article is

00:05:21.680 | "Pharmacologic Approach to Smoking Cessation,

00:05:24.400 | an Updated Review for Daily Clinical Practice."

00:05:27.120 | And even though this is mainly focused on smoking cessation,

00:05:30.400 | it carries over quite nicely to vaping.

00:05:32.920 | And it details a number of statistics.

00:05:34.600 | You know, the fact that every year,

00:05:36.200 | 700,000 or more people die

00:05:38.000 | because of smoking-related diseases.

00:05:39.480 | So there again, you have the negative health effects

00:05:42.520 | that younger people are smoking,

00:05:43.880 | that women are smoking more nowadays,

00:05:45.480 | and that even though you see less smoking

00:05:46.920 | typically in the U.S. and Canada

00:05:48.520 | and even in Northern Europe, some places,

00:05:50.440 | there's still many, many people are smoking

00:05:51.960 | who would like to quit.

00:05:53.240 | But that 75% of people,

00:05:55.360 | at least according to this review earlier,

00:05:56.640 | I said 70%, but estimates are as high as 75% of people

00:06:00.200 | who try to quit smoking relapse within the first week.

00:06:03.280 | The first week, they just go right back to it.

00:06:04.800 | That's how powerfully reinforcing the nicotine is.

00:06:07.320 | Remember, it's the nicotine in the cigarette

00:06:09.240 | that's powerfully reinforcing,

00:06:10.440 | but it's also the oral habit, the motor habit.

00:06:15.440 | You know, there is this thing

00:06:16.560 | about density of sensory receptors in the lips.

00:06:18.760 | People like bringing things to their lips.

00:06:21.100 | Food, cigarettes, other lips in some cases, et cetera.

00:06:27.000 | There is a reinforcement pathway related to that

00:06:29.520 | for sort of obvious adaptive reasons.

00:06:31.980 | And as a consequence,

00:06:34.480 | there is a reinforcement both from the behavior

00:06:37.120 | and from the dopamine released from the nicotine itself.

00:06:39.680 | And as I mentioned earlier,

00:06:41.080 | from the positive reinforcement

00:06:43.240 | that comes from increased focus,

00:06:44.440 | so the money that you make through work

00:06:45.800 | or your attentional ability

00:06:47.200 | or the fact that you're alert and people feel you present,

00:06:49.160 | all of that funnels back into positive reinforcement,

00:06:52.440 | behavioral reinforcement,

00:06:54.320 | and then what we would call addiction.

00:06:56.800 | So this review covers all of that

00:06:59.080 | and then steps beautifully

00:07:00.780 | through nicotine replacement therapy and various compounds,

00:07:04.320 | several of which I'm going to talk about now,

00:07:06.280 | which have been shown to increase that number

00:07:08.520 | that we talked about earlier of only 5% of people

00:07:11.160 | who try to quit with no other support,

00:07:13.640 | pharmacologic or hypnosis or otherwise,

00:07:15.400 | just say, that's it, I'm not going to smoke again

00:07:17.560 | or I'm not going to vape again.

00:07:19.200 | Only 5% of people succeed in doing that.

00:07:21.440 | And even among those, many end up relapsing later.

00:07:24.280 | There are a couple of pharmacologic approaches.

00:07:26.400 | One of the main ones that's received a lot of attention

00:07:28.320 | in recent years is bupripurone,

00:07:30.600 | sometimes referred to by its commercial name, Wellbutrin.

00:07:34.600 | Now, bupripurone is a compound

00:07:38.360 | that increases the release of dopamine

00:07:40.560 | and to a lesser extent, epinephrine

00:07:42.440 | and some other neurochemicals as well.

00:07:44.140 | It's used for the treatment of depression

00:07:46.160 | and for smoking cessation.

00:07:48.260 | Now, I want to point out, again, I'm not a psychiatrist,

00:07:50.440 | so I'm not telling you to take bupripurone aka Wellbutrin,

00:07:54.000 | but I'm going to give you a little bit of the contour

00:07:55.720 | of what's typically done

00:07:57.160 | in terms of bupripurone administration

00:07:59.000 | to help people get relief

00:08:00.920 | from some of the withdrawal symptoms

00:08:02.780 | of trying to quit smoking or vaping

00:08:04.440 | or other forms of nicotine ingestion.

00:08:07.080 | Typically, bupripurone is taken

00:08:09.360 | in 300 milligram per day doses

00:08:12.000 | divided into two dosages of 150 milligrams each,

00:08:14.720 | or sometimes there's a slow release formula.

00:08:17.760 | The dosages will vary from person to person.

00:08:20.440 | I want to really emphasize

00:08:21.940 | that there is an increased seizure risk with bupripurone.

00:08:25.200 | It only occurs in a small fraction of the population,

00:08:27.480 | but nonetheless is a real concern

00:08:29.520 | for those members of the population.

00:08:30.920 | So for those of you with seizure risk,

00:08:32.760 | whether you know it or not,

00:08:34.160 | that's going to be a valid concern

00:08:36.680 | in terms of potential side effects.

00:08:38.500 | The other thing about bupripurone

00:08:40.160 | is that it has to be used with caution in patients

00:08:43.440 | that have liver disease or renal disease

00:08:45.400 | that can impact the amount that anyone can take,

00:08:47.960 | meaning sometimes people have to take a much lower dose

00:08:50.200 | if they have renal disease or liver disease,

00:08:52.760 | and sometimes they can't take it at all.

00:08:54.440 | Sometimes if people are taking benzodiazepines

00:08:56.800 | for whatever reason or other sedatives,

00:08:58.720 | there are contraindications there.

00:09:00.280 | So bupripurone isn't a kind of one-size-fits-all

00:09:03.920 | or magic bullet for quitting smoking.

00:09:06.020 | Nonetheless, for people that can take it safely,

00:09:08.600 | and again, this is a prescription drug,

00:09:10.400 | a board-certified psychiatrist or other physician

00:09:12.720 | is going to have to prescribe it for you

00:09:14.120 | if it's appropriate for you,

00:09:15.200 | and it moves that number of 5% success rate

00:09:18.000 | to about what one sees with the clinical hypnosis

00:09:21.040 | to about 20% of people will successfully

00:09:25.600 | overcome their nicotine,

00:09:27.320 | or I should say their smoking or vaping addiction.

00:09:30.800 | Now, it's important to ask why this would work, right?

00:09:33.620 | I mean, it's not as if bupripurone

00:09:35.720 | is increasing nicotine per se.

00:09:38.760 | What it's doing is it's tapping

00:09:40.120 | on that mesolimbic reward pathway,

00:09:41.880 | increasing dopamine, or at least allowing dopamine levels

00:09:44.320 | to stay substantially elevated enough

00:09:47.100 | that people don't experience some of the drop in dopamine

00:09:50.440 | that leads to the withdrawal symptoms,

00:09:51.920 | the lessening of mood, et cetera.

00:09:53.440 | And it's no coincidence that bupripurone

00:09:55.120 | is also an antidepressant.

00:09:56.940 | It's a common antidepressant for people

00:09:58.880 | that experience negative side effects

00:10:00.280 | with the so-called SSRIs,

00:10:01.840 | the Selective Serotonin Reuptake Inhibitors,

00:10:04.400 | that prevent them from taking those things

00:10:05.920 | like lessened libido or appetite,

00:10:07.720 | or in some cases, increased appetite,

00:10:09.840 | or any number of other side effects

00:10:11.320 | that some people, not all,

00:10:12.560 | but some people experience with SSRIs.

00:10:14.280 | They'll be prescribed Welbutrin, bupripurone

00:10:17.200 | is the generic name,

00:10:18.720 | so Welbutrin being the commercial name.

00:10:20.440 | Again, bupripurone is what they'll be prescribed instead.

00:10:24.720 | With the caveats of seizure risk,

00:10:26.980 | renal disease, liver disease, et cetera,

00:10:29.420 | the outcomes with Welbutrin for smoking cessation

00:10:32.940 | are pretty good.

00:10:33.780 | I mean, if you think about an increase from 5% to 20%,

00:10:36.460 | that's pretty dramatic.

00:10:37.620 | And yet, I also want to refer back

00:10:39.340 | to the incredible success of the clinical hypnosis approach.

00:10:42.620 | Again, you can find that at reverie.com.

00:10:45.220 | The clinical hypnosis approach has a success rate of 23%,

00:10:49.340 | so it's very closely aligned with,

00:10:51.300 | if not exceeding, the success rate with bupripurone.

00:10:54.920 | Of course, there are other pharmacologic approaches

00:10:57.080 | to quitting smoking or vaping.

00:11:00.120 | All of them generally circle back to increasing dopamine

00:11:03.560 | and/or norepinephrine

00:11:04.920 | in order to offset some of the withdrawal symptoms

00:11:07.560 | of smoking cessation or vaping cessation.

00:11:10.240 | A very common approach for people

00:11:12.280 | to try and quit smoking or vaping

00:11:14.400 | is to use nicotine itself

00:11:17.400 | to try and prevent people from seeking nicotine

00:11:20.360 | through a cigarette or a vape pen.

00:11:22.800 | What I mean by that is people using a nicotine patch

00:11:25.760 | or nicotine gum or other nicotine delivery device

00:11:29.600 | that is not cigarettes and not vaping

00:11:32.520 | in order to maintain levels of nicotine in their bloodstream,

00:11:37.520 | which of course means maintain levels of nicotine

00:11:39.780 | in their brain and body,

00:11:41.720 | to the same extent that they would

00:11:43.600 | if they were smoking or vaping,

00:11:45.560 | maybe even gradually taking down the total amount

00:11:48.920 | of nicotine in their brain and body

00:11:50.680 | by reducing the number or size of nicotine gum pieces

00:11:55.480 | that they ingest each day,

00:11:56.920 | or keeping the patch on for a shorter amount of time,

00:11:59.540 | or getting a lower dose patch

00:12:00.880 | that releases less nicotine total or over time.

00:12:04.840 | All of those approaches have been shown

00:12:07.720 | to be reasonably successful.

00:12:09.640 | I'll get to the numbers in a few minutes,

00:12:10.700 | but reasonably successful

00:12:12.360 | in allowing people to quit smoking or vaping.

00:12:17.660 | Again, most of the data is on cigarette smoking

00:12:20.280 | because vaping is a relatively new phenomenon,

00:12:22.740 | although quite troublingly,

00:12:25.000 | it's a very rapidly increasing behavior,

00:12:28.340 | especially in the young population.

00:12:29.840 | So that's why I'm kind of lumping these two things together

00:12:31.960 | because I think very soon we are going to need

00:12:35.960 | an all-out campaign for how to counter vaping addiction.

00:12:40.100 | So what do we know about smoking sensation

00:12:42.440 | using nicotine itself?

00:12:44.080 | Is the patch best?

00:12:45.320 | Is nicotine gum best?

00:12:47.040 | It turns out that a combination of approaches is best.

00:12:51.060 | So somewhat surprising,

00:12:52.160 | but it was very clear from the literature

00:12:53.360 | that I was able to find that using nicotine patches

00:12:56.720 | for some period of time, and then switching to a gum,

00:12:59.760 | and then perhaps switching to a nasal spray,

00:13:03.680 | that's going to be the most effective.

00:13:05.480 | Then the question is how long to continue each of those

00:13:08.640 | and whether or not to overlap them.

00:13:10.120 | It seems as if doing one for about a week

00:13:12.640 | and then switching to another for about a week

00:13:14.240 | and then switching to another

00:13:15.560 | is one rational and reasonable approach

00:13:18.320 | that many people have used successfully.

00:13:20.700 | Why would that be?

00:13:21.540 | Well, it all has to do with the different rates

00:13:23.240 | of absorption of nicotine into the bloodstream,

00:13:26.040 | and then the downstream consequences of that

00:13:28.280 | on the dopamine, acetylcholine, epinephrine,

00:13:30.960 | and other systems of the brain and body.

00:13:33.120 | And while there hasn't been an extremely detailed study

00:13:36.480 | of the exact kinetics of how the nasal sprays

00:13:39.400 | versus the transdermal patches

00:13:40.760 | versus the gums, et cetera, work,

00:13:42.600 | there's a logical structure to it

00:13:44.060 | that will immediately make sense to you.

00:13:45.400 | First of all, the transdermal patches

00:13:47.840 | provide a fairly steady state dopamine release

00:13:50.680 | across the day,

00:13:51.920 | and oftentimes people are wearing them at night as well.

00:13:54.280 | This is relevant because if people are ingesting nicotine

00:13:57.360 | by way of smoking and vaping,

00:14:00.580 | you know, hopefully they're not waking up

00:14:01.920 | in the middle of the night just to smoke or vape,

00:14:03.320 | or believe it or not, some people do that.

00:14:04.720 | But of course, while people are asleep,

00:14:06.920 | they are not smoking or vaping.

00:14:09.040 | They always tell you don't fall asleep

00:14:10.000 | with a cigarette in your mouth,

00:14:10.820 | you burn the whole house down.

00:14:12.840 | But exceedingly rare to have people

00:14:16.000 | who are smoking in their sleep.

00:14:17.540 | So people wake up in the morning,

00:14:19.120 | and because the half-life of nicotine

00:14:21.280 | from smoking or vaping is very short,

00:14:22.640 | anywhere from one to two hours,

00:14:24.560 | they are essentially in a state of withdrawal

00:14:26.160 | at the point where they wake up in the morning.

00:14:27.520 | How can I say that?

00:14:28.360 | Well, remember, withdrawal sets in about four hours

00:14:30.960 | after the last ingestion of nicotine by cigarette

00:14:33.720 | or by inhalation from the vape pen.

00:14:35.600 | So people are waking up in nicotine withdrawal,

00:14:38.280 | and then immediately going into the behavior

00:14:40.560 | of ingesting nicotine or very soon after waking

00:14:42.600 | for most people.

00:14:44.160 | So nicotine patch is going to be very effective

00:14:47.120 | for a week or so.

00:14:48.160 | Again, talk to your physician

00:14:49.160 | about the best approach for this.

00:14:51.000 | But then switching to a nasal spray

00:14:54.440 | or switching to nicotine gum for about a week,

00:14:56.680 | which is going to change the kinetics

00:14:58.160 | of that nicotine absorption to the bloodstream

00:15:00.240 | and change the release of dopamine

00:15:02.680 | and other neurochemicals within the brain,

00:15:04.320 | that's going to keep the system intentionally off balance

00:15:07.760 | so that it never comes to expect one single pattern

00:15:11.400 | or amplitude of dopamine release.

00:15:14.560 | And that is a very powerful way for a,

00:15:18.200 | let's just call it a quitting method to work

00:15:22.240 | because as I've always said,

00:15:23.880 | the most powerful schedule of dopamine

00:15:26.800 | is going to be this random intermittent reward.

00:15:29.680 | This is what's used in the casinos

00:15:31.400 | in order to take your money.

00:15:32.640 | And generally they do, on average,

00:15:34.300 | they take your money more than you take theirs,

00:15:36.840 | and they take more of it, not just more often,

00:15:39.880 | because they use this random intermittent schedule.

00:15:42.360 | The random intermittent schedule

00:15:43.760 | is one in which you don't really know

00:15:45.400 | when the peaks in dopamine are going to arrive.

00:15:47.840 | And so there isn't this expectation and craving.

00:15:50.320 | And then all of a sudden when dopamine is released,

00:15:52.040 | it's extremely high.

00:15:52.920 | That's how they get you to continue playing,

00:15:54.300 | even though basically you're losing money

00:15:55.880 | and your dopamine is dropping,

00:15:56.880 | they elevate it every once in a while.

00:15:59.760 | Nicotine replacement can be used in a similar way,

00:16:02.280 | but in a benevolent way in order to help you get over

00:16:05.280 | smoking or vaping.

00:16:06.800 | By keeping the total amounts of dopamine variable

00:16:09.600 | around the clock,

00:16:11.280 | and by changing the amount of dopamine that's released,

00:16:14.120 | it seems to help people behaviorally and psychologically

00:16:17.520 | because they don't come to expect

00:16:18.940 | having a particular amount of dopamine

00:16:20.460 | in their brain and blood at any given time.

00:16:23.080 | (upbeat music)

00:16:25.660 | (upbeat music)

00:16:28.240 | (upbeat music)

How to Quit Smoking, Vaping or Dipping Tobacco | Dr. Andrew Huberman

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