What if we do relapse? What then? Hopefully, relapse will instill a deep and profound respect for the power of one hit of nicotine to again take the mind's priorities teacher hostage.
Hopefully, belief in the Law of Addiction will thereafter forever remain beyond question. Hopefully, we'll immediately work toward reviving and strengthening our dreams and start home again soon. But if not, what then?
And what if relapse was to the dirtiest, most destructive, and deadliest form of nicotine delivery ever devised, the cigarette?
We're told it accounts for 20% of all deaths in developed nations.[1] According to the World Health Organization, smoking is expected to claim more than a billion nicotine addicts by century's end.
My late friend and nicotine toxicologist Heinz Ginzel, MD wrote, "burning tobacco ... generates more than 150 billion tar particles per cubic inch, constituting the visible portion of cigarette smoke. But this visible portion amounts to little more than 5 to 8 percent of what a lit cigarette discharges and what you inhale during puffing. The remaining 90% of the total output from a burning cigarette is in gaseous form and cannot be seen."[2]
Those unseen gases include carbon monoxide, hydrogen cyanide, hydrogen sulfide, ammonia, and methane.
Many health advocates wish they could immediately transfer all smokers to less destructive forms of nicotine delivery. And many are now strongly advocating it.
How many fewer deaths would occur? We really don't know. While most harm reduction advocates are extremely optimistic and expect massive reductions, their suppositions ignore the fact that most smokers have already logged years of tobacco toxin and carcinogen exposure.
And how does continuing use of the super-toxin nicotine factor into the damage being done?
What are the long-term risks associated with electronic cigarettes, heat not burn tobacco products, and replacement nicotine in long-term ex-smokers? It may take decades before science can untangle relative risks and draw reasonably reliable conclusions.
As for any traditional combustion-type cigarette claiming to be "natural" or less harmful than other brands, don't buy it. Inhaling gases and particles from a burning toxic waste dump isn't just inherently dangerous and extremely destructive, it's deadly.
A 2008 study examined the effects of smoke upon normal embryonic stem cell development from three cigarette brands suggesting harm reduction benefits. It found that smoke from these so-called harm-reduction cigarettes inhibited normal cell development as much "or more" than traditional brands.[3]
Some public health advocates are alarmed that harm reduction campaigns may actually backfire, keeping millions who would have successfully arrested their chemical dependency hooked and cycling back and forth between cigarettes and other forms of nicotine delivery.
They're seeing a significant percentage of smokers coaxed into trying e-cigs end-up hooked on both cigs and e-cigs. They're called "dual-users."
A 2020 study focused on use-status changes among surveyed dual users between 2013 and 2016. It found that while two years later 7% of dual users had become e-cig only users, and 12% were able to stop using all tobacco products, that 26% were still dual users, and 55% had returned to smoking.[4]
That's right, more than 80% still smoking. In fairness, nicotine delivery technology has advanced since Juul and nicotine salts were introduced in 2015. Has that changed things?
It certainly has for teens.
It appears that the primary aim of Juul marketing wasn't in helping smokers get off of cigarettes but in addicting youth.
Marketing showing young people vaping Juuls, their friends doing it, an array of tempting flavors, with thousands of social media posts throwing around terms like "safe" and "safer," how could kids resist?
Although sickening, my concern isn't only about a new generation of youth becoming nicotine addicts.
Is there any question but that the neo-nicotine industry will do its damnedest to keep them enslaved and buying until death, its damnedest to suppress efforts to free them, and its damnedest to entice complacent ex-users to relapse and join them?
I hold in my hand sample packets containing two 2mg pieces of "Fresh Fruit" and "Ice Mint" Nicorette gum with tooth whiteners. I was told that these sample packs were being sold at self-service checkout counter displays in Canadian beer stores for one penny.
How many ex-smokers will be tempted to give it a try while drinking alcohol? How many will relapse?
The second sentence on the back of each Canadian sample pack tells smokers that Nicorette gum isn't just for stopping smoking.
"Nicorette gum can also be used in cases in which you temporarily refrain from smoking, for example in smoke-free areas or in other situations which you wish to avoid smoking."
Imagine pharmaceutical companies dove-tailing their marketing with that of tobacco companies in order to make continued smoking easier or more convenient.
Have you ever wondered why you've never once heard any nicotine gum or patch commercial suggest that "Smoking causes lung cancer, emphysema, and circulatory disease, that you need to buy and use our product because smoking can kill you"?
You haven't and likely never will. But why?
As hard as this may be to believe, the pharmaceutical and tobacco industries have operated under a nicotine marketing partnership agreement since about 1984. Once secret documents evidencing their agreement are many, and suggest that neither side may directly attack the other's products.[5]
The obvious purpose of their partnership is to ensure the purchase and use of each side's dopamine pathway stimulation products. They want you to pay them to satisfy your dependency's wanting. The purpose of this book is to aid you in arresting it.
Back to harm reduction where all profiting are encouraging drug addicts to never stop using.
Some opposed to harm reduction have argued that the risks associated with a smoker transferring to oral tobacco is like getting hit by a small car instead of a large truck, like shooting yourself in the foot instead of the head, or like jumping from a three-story building rather than one that's ten stories tall.
Lacking accurate relative risk data themselves, the harm reductionist counters by asserting that, "Based on the available literature on mortality from falls, we estimate that smoking presents a mortality risk similar to a fall of about 4 stories, while mortality risk from smokeless tobacco is no worse than that from an almost certainly non-fatal fall from less than 2 stories."[6]
"We estimate"? It's disturbing to see us stoop to educated-guessing when it comes to life or death.
It is also disturbing that no serious harm reduction advocate has yet been willing to provide an accurate accounting of known and suspected harms associated with long-term nicotine use.
They know that the amount of nicotine needed to kill a human is more than one hundred times less than the amount of caffeine needed to do so (40-60 milligrams versus 10 grams).[7]
Yet, many have resorted to falsely portraying nicotine as being as harmless as caffeine in order to sell smokers on "safer" delivery. How many coffee drinkers carry the pot with them?
Harm reduction advocates initially did little to address concerns about the impact of marketing upon youth, messages bombarding them with a wide array of tempting flavors being portrayed as vastly safer than smoking.
They were silent as adolescent nicotine harm studies evidenced nicotine's horrific toll on the developing adolescent brain.[8]
Let me share one youth use-risk concern among many. Ever wonder why those who started using nicotine as children or early teens tended to have greater difficulty learning?
Research shows that adolescent nicotine disrupts normal development of auditory brain fibers. This damage may interfere with the ability of these fibers to pass sound, resulting in greater noise and diminished sound processing efficiency.[9]
Harm reduction advocates not only ignore the harms inflicted by nicotine, they ignore nicotine's greatest cost of all, living every hour of every day as an actively feeding addict.
They must, otherwise they couldn't sell it. Their focus is upon disease and dying that's likely years or decades down the road, not on living, and today's quality of life.
Some have resorted to accusing nicotine cessation advocates who are unwilling to incorporate harm reduction lessons into their recovery programs as having a "quit or die" mentality.
It is as if they have no appreciation for the fact that bargaining is a normal phase of recovery, and that there is no more inviting bargain for an addict than one which invites them to keep using.
It's why it pains me to include this harm reduction section here at the tail end of this book.
I worry that some new struggling ex-user reading this book, who would have succeeded if this section hadn't been here, will instead seize upon the words that follow as license to relapse.
But the alternative, the potential for relapse and then smoking yourself to death because relative risk was never discussed or explained, is unacceptable.
Still, as Dr. Ginzel noted, it would be nice if we knew the actual relative risks in contrasting even smokeless tobacco to NRT but we don't.
What is the relative risk when comparing cigarettes to oral tobacco, or to electronic cigarettes, or to heat not burn products, or to replacement nicotine? Frankly, science doesn't yet know.
We know that cigarettes currently contribute to nearly five million deaths annually, and that they release 4,000 to 6,000 chemicals, while oral tobacco is known to release about 2,550 chemicals. We also know that as many as 81 potential cancer-causing chemicals have been identified in cigarette smoke[10] versus 28 in oral tobacco.[11]
Even nicotine's relationship to cancer, it's still being studied and debated.
As for e-cigarettes, although a 2019 study linked vaping nicotine to causing cancer in mice,[12], in fairness, mice are not humans. Still, there's near consensus that nicotine promotes the proliferation, migration, and invasion of cancer cells in a dose-response manner.[13]
As for the safety of vaping e-cigs, ask yourself this. If vaping is already being blamed for damaging DNA methylation, inducing birth defects, and affecting heart and lungs development in the of offspring in animal studies, how safe can it be for us or our offspring?[14]
Additional research is badly needed as we have little long-term heath-risk data for pure nicotine users. Most of us have years of cigarette or oral tobacco exposure.
Clearly, smokers face super-serious risks of many different types of cancers, a host of breathing disorders including emphysema, and circulatory disease as carbon monoxide combines with nicotine to destroy vessel walls and facilitate plaque buildup.
Most smoking's risks, with its 50% adult kill rate, are well known. Like e-cigs, what wasn't being studied until recently were the health concerns expressed by long-term NRT users.
Although we still don't know whether or not NRT user health concerns are in fact directly related to long-term nicotine use, online nicotine gum user complaints include:
Addiction with intense gum cravings, anxiety, irritability, dizziness, headaches, nervousness, hiccups, ringing in the ears, chronic depression, headaches, heart burn, elevated blood pressure, a rapid or irregular heart beat, sleep disruption, tiredness, a lack of motivation, a heavy feeling, recessed, bleeding and diseased gums, diminished sense of taste, tooth enamel damage, tooth loss, jaw-joint pain and damage (TMJ), canker sores with white patches on the tongue or mouth, bad breath, dry mouth, sore or irritated throat, difficulty swallowing, swollen glands, bronchitis, stomach problems and pain, gastritis, severe bloating, belching, achy muscles and joints, pins and needles in arms and hands, uncontrollable foul smelling gas that lingers, a lack of energy, loss of sex drive, acid reflux, stomach ulcers, fecal impaction from dehydration, scalp tingling, hair loss, acne, facial reddening, chronic skin rashes and concerns about immune system suppression.[15]
As you can see, while the list of unproven possibilities are many, few concerns come anywhere near smoking's known risks. Clearly, smoking's harms are vastly greater and far more life threatening than nicotine's.
How many millions of additional air sacs would these lungs have today if I'd permanently transferred my dependency to nicotine gum the first time I used it in 1985 or 86?
If my goal had been long-term nicotine gum use instead of the 8 to 12 weeks FDA use instructions then limited use to, would I have been more willing to accept gum's slower, less precise, and less controllable delivery? If I'd permanently transferred my dependency to cleaner delivery in 1986, would I be able to run for more than a few hundred feet today? Would I have more teeth?
If I had allowed myself to become hooked on the cure, as an estimated 37% of U.S. nicotine gum users were as of 2003,[16] would I have had the motivation to eventually break free from all nicotine, as I did on May 15, 1999, or would gum use have taken away my greatest recovery motivation of all, the fear that smoking was killing me, that I was running out of time and chances?
Would I have created WhyQuit two months later in July? Would I have met Joel Spitzer in January 2000? Would this book have been written?
I don't know. Maybe, maybe not.
Hopefully you're feeling my reluctance to suggest that if you relapse to smoking nicotine, that if a non-pregnant adult, that you consider attempting to adapt to a cleaner form of delivery. But there, I've done it. You should.
And if considering e-cigarettes, be advised that 2015 research indicates that you may need to inhale, puff and suck on an e-cigarette at least 1 full second longer than you normally would if puffing on a cigarette.
Quoting from the study, "Smokers are used to inhaling from a cigarette that is already burning, while electronic cigarette use is associated with aerosol production only at the time of activation. This can cause a substantial delay between activation and production of [a] sufficient amount of vapor. Experienced users compensate [for] this by activating ECs for [a] longer time, taking longer puffs."[17]
"Moreover, while smokers can draw 'harder puffs' (i.e. can elevate the puff volume which will accelerate the burning process and produce more smoke without increasing the puff duration), such a pattern has no effect on aerosol production from electronic cigarettes."
According to the study, failure to inhale at least a full second longer will result in reducing the amount of nicotine entering the bloodstream by about half. And half may not be enough to satisfy your need. So, if you're going to give electronic nicotine a fair chance you need to substantially extend how long you inhale.
But as a nicotine cessation educator, my dream isn't about seeing you develop the patience needed to allow you to adapt to and remain slave to a cleaner and less destructive forms of delivery.
It's in seeing you develop the "one day at a time" patience needed to go the distance and allow yourself to sample the amazing sense of quiet and calm that arrives once your addiction's chatter goes silent.
References:
2. Ginzel, KH, Why Do You Smoke? WhyQuit.com, February 6, 2007.
3. Lin S, et al, Comparison of toxicity of smoke from traditional and harm-reduction cigarettes using mouse embryonic stem cells as a novel model for preimplantation development, Human Reproduction, November 29, 2008 [Epub ahead of print].
4.Osibogun O et al, Cessation outcomes in adult dual users of e-cigarettes and cigarettes: the Population Assessment of Tobacco and Health cohort study, USA, 2013-2016, International Journal of Public Health, July 24, 2020, doi: 10.1007/s00038-020-01436-w. Online ahead of print.
5. Shamasunder B, Bero L., Financial ties and conflicts of interest between pharmaceutical and tobacco companies, Journal of the American Medical Association, August 14, 2002, Volume 288(6), Pages 738-744; also see the following once secret tobacco industry documents available at TobaccoDocuments.org: PM USA internal memo dated 7/21/82, Bates #2023799798; PM USA internal memo dated 5/7/84, Bates #2023799799; PM USA internal memo dated 10/25/84, Bates #2023799801; PM USA letter dated 12/17/84, Bates #2023799804; PM USA internal memo dated 1/22/85, Bates #2023799803; PM USA internal memo dated 9/6/85, Bates #2023799796; 2nd PM USA internal memo dated 9/6/85, Bates #2023799795; PM USA internal memo dated 12/16/85, Bates #2023799789; PM USA internal memo dated 1/8/88, Bates #2500016765; PM USA letter dated 5/8/91, Bates #2083785672; British American Tobacco collection letter dated 8/1/91, Bates #500872678; PM International letter dated 4/23/98, Bates #2064952307.
6. Phillips CV, et al, Deconstructing anti-harm-reduction metaphors; mortality risk from falls and other traumatic injuries compared to smokeless tobacco use, Harm Reduction Journal, April 18, 2006, Volume 3, Pages 1-5.
7. Polito, JR, Nicotine 166 Times More Deadly than Caffeine? WhyQuit.com, February 16, 2006.
8. Slotkin TA, et al, Adolescent nicotine treatment changes the response of acetylcholine systems to subsequent nicotine administration in adulthood, Brain Research Bulletin, May 15, 2008, Volume 76 (1-2), Pages 152-165; also see, Slotkin TA, If nicotine is a developmental neurotoxicant in animal studies, dare we recommend nicotine replacement therapy in pregnant women and adolescents? Neurotoxicology and Teratology, January 2008, Volume 30, Issue 1, Pages 1-19.
9. Jacobsen, LK, et al, Prenatal and Adolescent Exposure to Tobacco Smoke Modulates the Development of White Matter Microstructure, The Journal of Neuroscience, December 5, 2007, Volume 27(49), Pages 13491-13498.
10. Smith CJ et al, IARC carcinogens reported in cigarette mainstream smoke and their calculated log P values, Food and Chemical Toxicology, June 2003, Volume 41(6), Pages 807-817.
11. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Smokeless Tobacco and Some Tobacco-specific N-Nitrosamines, 2007, Volume 89.
12. National Institute of Health, E-cigarette vapor linked to cancer in mice, NIH Research Matters, November 5, 2019, https://www.nih.gov/news-events/nih-research-matters/e-cigarette-vapor-linked-cancer-mice Viewed 08/09/20.
13. Ben Q et al, Nicotine promotes tumor progression and epithelial-mesenchymal transition by regulating the miR-155-5p/NDFIP1 axis in pancreatic ductal adenocarcinoma, Pancreatology, June 2020 Jun, Volume 20(4), Pages 698-708. 1016/j.pan.2020.04.004. Epub 2020 Apr 20.
14.Cardenas VM et al, The use of electronic nicotine delivery systems during pregnancy and the reproductive outcomes: A systematic review of the literature, Tobacco Induced Diseases, July 2019, 17:52. doi: 10.18332/tid/104724.
15. Polito JR, Long-term Nicorette gum users losing hair and teeth, WhyQuit.com, December 1, 2008.
16. Bartosiewicz, P, A Quitter's Dilemma: Hooked on the Cure, New York Times, Published: May 2, 2004; quoting, Shiffman S, Hughes JR, et al, Persistent use of nicotine replacement therapy: an analysis of actual purchase patterns in a population based sample, Tobacco Control 2003 November; 12: 310-316.
17. Farsalinos, KE et al. Nicotine absorption from electronic cigarette use: comparison between experienced consumers (vapers) and naïve users (smokers). Sci. Rep. 5, 11269; doi: 10.1038/srep11269 (2015).
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