Connor Dorr: At first, I proceeded to shake [for] 48 hours after I quit because you're going through full withdrawal at that point, but I was just shaking. It was a very surreal experience. Then I'd be around my friends and I'd smell the cigarette smoke. My mouth would water. I was like, "Let me try that. Let me try that." Allison Sekuler: That's our guest, Connor Dorr. Like millions of people worldwide, he tried to quit smoking and vaping. As you'll hear today, when people quit, their brains thank them. Jay Ingram: Welcome to Defy Dementia, the podcast for anyone who has a brain. Allison Sekuler: Defy Dementia is about many aspects of dementia, like destigmatizing it, but at its heart, it's about living in ways that keep our brains healthy and reduce our risk of dementia. That's because dementia is not dictated by our genes. Genetics can play a role, but lifestyle risk factors like poor sleep and social isolation and a lack of exercise can also have a significant impact. Jay Ingram: As we've said before on this show, the best evidence tells us that if we make healthy changes to key lifestyle risk factors, we could reduce dementia cases worldwide by at least 45%. Allison Sekuler: And today on the show, we're talking about one of the most important lifestyle risk factors and one we have not talked about before, smoking. Jay Ingram: It's no surprise that smoking is bad for our health and hugely addictive, but now, there's new information on what it does to the brain. If you're a smoker, there is a hopeful side to this topic. Both are worth hearing. Allison Sekuler: I'm Allison Sekuler, President and Chief Scientist at the Baycrest Academy for Research and Education and at the Centre for Aging and Brain Health Innovation. Jay Ingram: I'm Jay Ingram. I'm a science journalist. I've been reporting on brain research for most of my career. Allison Sekuler: Join us as we defy dementia because you're never too young or too old to take care of your brain. Jay Ingram: If you smoke tobacco or if you know or love a smoker, this show is for you. We're going to start the show with a confession. When we began Defy Dementia more than two years ago, we looked at the list of well-established risk factors for dementia, like poor diet, insufficient exercise, and social isolation. Smoking was on that initial list, identified as a major risk factor, but at the time, we thought it was such a well-known health hazard that we set it aside. But after researching smoking for this episode, we realized it deserves a hearing. Allison Sekuler: And smoking tobacco is an important and fascinating topic that deserves a closer look because so many people smoke. According to the government of Canada, in 2022, about 12% of Canadians over the age of 15 were smokers. The World Health Organization estimates that there are 1.3 billion smokers worldwide. Jay Ingram: That is a staggering number. To support those people, we're going to explore why it makes sense to think of smoking as a medical condition, not a vice. Allison Sekuler: And later on the show, we're going to hear from a 22-year-old former smoker who first got hooked on nicotine in the bathroom when he was in high school. Jay Ingram: Now, some of the smokers in our audience might wonder what they have in common with Connor, but even if you've been smoking for a half a century, I'd say it's a good bet that you're going to hear echoes of your story in his. Allison Sekuler: But first, a look inside the brain, how lighting up tobacco fires up dementia risk. Jay Ingram: Our first guest is an expert on that very topic. Dr. Adrienne Johnson studies the link between smoking and dementia risk. She's an assistant professor in the Department of Medicine at the University of Wisconsin School of Medicine and Public Health. She's also an investigator at the University Center for Tobacco Research and Intervention and a faculty affiliate at the Wisconsin Alzheimer's Disease Research Center. In addition to being a researcher, Dr. Johnson is also a hands-on psychologist who works in a clinic where she helps people living with mild cognitive impairment, or mild dementia, cope with those diagnoses. She also, on occasion, helps patients quit smoking. She joins us from Madison, Wisconsin. Dr. Johnson, thank you for helping us defy dementia. Dr. Adrienne Johnson: Thank you so much for having me today. Happy to be here. Jay Ingram: Adrienne, before we get into dementia risk, what do people need to know about the addictive effect of smoking tobacco on the brain? Dr. Adrienne Johnson: That's a really great question. Nicotine, which is the main addictive ingredient in cigarettes, is extremely addictive. I like to tell my patients that it hits your brain as fast as heroin does, so within five to seven seconds. When we think about the number of times people have to try to quit to be successful, we're usually getting above 7, 10 times. So, we know it is extremely addictive. Jay Ingram: Why do you think it's important for people to know that? Dr. Adrienne Johnson: I think it's important for people to know that so they can remember that it is a chronic medical condition and we should be treating it as such. So, with that in mind, taking away the stigma of someone who is smoking and remember that that is an addiction, a medical condition, and also providing support in the form of evidence-based treatment to help people quit and stay quit. Allison Sekuler: So knowing that people are going to have difficulty quitting and that there are a number of people out there still smoking, how significant [of] a dementia risk factor is smoking tobacco? Dr. Adrienne Johnson: It is one of the modifiable risk factors for dementia. So, what that means, it's a risk factor that we can change, thankfully. We know that people who are currently smoking are about 70% more likely to develop dementia than people who never smoked. Allison Sekuler: So that was for all forms of dementia, not just Alzheimer's? Dr. Adrienne Johnson: Correct. Great point. That was for all forms of dementia. There are other estimates looking specifically at Alzheimer's disease. They tend to be a little bit lower in about the 30 to 40% range, but when we look at all forms of dementia, we're looking at a 70% increased risk. Allison Sekuler: So how does smoking tobacco impact people's risk of dementia? Dr. Adrienne Johnson: Yeah, so combustible cigarettes or commercialized cigarettes have 7,000 chemicals in them. We know that there are about three main ways that cigarette smoking impacts dementia. The first is through oxidative stress, and that's basically through an excessive amount of molecules that are very reactive, very excited. They're trying really hard to bond to the other molecules. What that can cause is cell damage and cell death. When that happens in the brain, obviously, when our cells are dying, they're not functioning as well. The second is neuroinflammation. We know through many research studies that smoking increases inflammation in our body, in our bloodstream, and we also know that it would therefore increase inflammation in our brain. [You can think] of a straw and the straw is getting thicker and thicker. So, it's harder for things to pass through it. The straw is your blood vessels. So, when it gets thicker, it's harder for us to function, and in the brain, it's harder for us to think. And so, inflammation is one of the main precursors to all types of dementia, particularly to Alzheimer's disease. Then the third is cardiovascular factors. We know that the heart is pumping blood to the whole body, including the brain. [And] when we think about how that's impacting brain health, we know that in an indirect way, smoking is impacting a lot of the [other] risk factors for dementia. It's impacting [the risk of] strokes, which is a huge risk factor for dementia. It's impacting diabetes, it's impacting heart disease, it's impacting all these other issues. There's actually a total of eight risk factors that smoking directly affects, that then lead to a diagnosis of dementia, including Alzheimer's disease. Jay Ingram: And Adrienne, when we were researching this show, we came across the fact that a lot of people may have heard that a component of tobacco actually has a protective effect against dementia. Is there any truth to that? Dr. Adrienne Johnson: I am so glad you brought that up because again, when we talk about cigarettes, that's 7,000 chemicals. One of which is nicotine, the main addictive ingredient. Nicotine alone is a stimulant. What that means is it can increase or improve our short-term memory. It's important to note that there are some studies looking at the potential effect of solely nicotine provided through a transdermal nicotine patch in improving short-term memory for people who are already experiencing cognitive impairments, but that in no way is the same as cigarette [smoking] that has [been] shown time and time again to have long-term negative cognitive effects. Allison Sekuler: So smoking tobacco damages cognitive health and boosts your dementia risk. I think it's pretty clear from what you said that that is the case. But if somebody quits, is that damage permanent? Because I'm thinking some people might be saying to themselves, "Well, the damage is already done, so there's no point in quitting. Let's just go out for a smoke." What do you say when people tell you that? Dr. Adrienne Johnson: I say that thankfully, you can make a change and it will make a difference. Research has shown that within as little as three years of quitting, you can be comparable to somebody who has never smoked cigarettes in terms of your dementia risk. The estimates usually range from about three to nine years, depending on the type of dementia and the different studies, but I think that's a really strong message. The other thing I would like to say is that there's other studies showing that quitting is especially important rather than cutting down. So, when we think about addictive substances, there's this idea of harm reduction, which can be beneficial, but for dementia, we know that you've got to quit. You've got to fully stop. That's what we really promote for all of our patients who are at risk for dementia, which includes older adults as well as middle-aged and younger adults. Allison Sekuler: So it's never too late to quit smoking, it sounds like. Dr. Adrienne Johnson: Never too late and particularly important for our older adults. I actually just completed and published a review of how older adults can quit smoking successfully. What we found is that older adults are more successful than younger adults when they use evidence-based treatment and try to quit smoking. So, you can still do it at any age, and there's still a huge benefit. Jay Ingram: Having said that, many young people are not unaware of the risks of smoking and yet still love, I guess, the effects of nicotine. What about vaping? Is there a dementia risk associated with that? Dr. Adrienne Johnson: So vaping is pretty new in the world of tobacco research. We've had decades to learn about the long-term effects of cigarettes, and unfortunately, the negative effects. For vaping, we are learning more and more about the negative effects, but we don't know enough yet to say whether vaping is associated with an increased risk of dementia. There's been some research showing it may have some effect on cognitive functioning in college students and other research looking at the other chemicals. So, vapes in comparison to cigarettes have 2,000 chemicals in them rather than 7,000. Allison Sekuler: That's really interesting. On other episodes of Defy Dementia, we've talked about air pollution as a dementia risk and we've also talked about the emerging relationship between wildfire smoke, which is everywhere and its effect on dementia risk. To what extent is smoking cigarettes unhealthy for us for the same reasons that air pollution or wildfire smoke is unhealthy, or is there really something extra going on when people are smoking cigarettes? Dr. Adrienne Johnson: It is similarly bad for those same reasons [but] there are extra carcinogens in nicotine tobacco products, particularly combustible cigarettes. It's important to note that it's at a much higher concentration and it's also something that we can control. Again, smoking is an addictive behavior. It is something that is very hard to change, but it is something that you can change with the right support. When we think about secondhand exposure to other environmental issues, we think about secondhand as in those who are around it and [can] not control it. The one person who is smoking is likely exposing those around them, whether they're living with them or not. So, that's why it's different. Allison Sekuler: Can I ask you something about filters for example? We've talked about how with air pollution, it's good to have air filters in your house and people. I've heard sometimes that smoking's not as bad if you're using filtered cigarettes versus unfiltered cigarettes. For dementia, is that a fair thing to say or it's not really filtering out what the problem is? Dr. Adrienne Johnson: It's definitely not filtering out the problem. When we talk about filtered cigarettes, that's something that in my understanding has largely been promoted by the tobacco industry as a way to make it feel healthier, when in fact it's not healthier. So, it's not protecting you from the things that maybe an air filter for wildfire exposure would do. So, it's important to note that and don't feel bad if you thought that because again, this is coming from an industry that is trying to sell a product. Allison Sekuler: So the filters that we have in the house might be specifically aimed at filtering out those very, very tiny particles, the PM 2.5s that we've talked about before. The filters in cigarettes are not filtering those sorts of things out. Dr. Adrienne Johnson: No, they're filtering for taste. They're filtering so it tastes a little less harsh. So, you can actually continue to do this behavior and you don't gag fully when you're doing it. Jay Ingram: Adrienne, we all know that humankind has spent many centuries figuring out how to inhale smoke of one kind or another. But now there's so many ways, and we would all like to know, do they have some impact on dementia? So there's tobacco, there's marijuana cigarettes, there's cigars, pipes, bongs, hookahs. Do we know anything about the dementia risk of those various ways of inhaling smoke? Dr. Adrienne Johnson: That's a great question. So, the greatest amount of research has been done on combustible tobacco cigarettes, and that showed pretty clearly that when you smoke and are actively smoking or a current smoker, you have an increased risk for developing dementia. Similarly, when you quit smoking, soon after, you can reduce that risk. There has been some recent research on cannabis use, although it's unclear if it's on smoking rather than other forms of cannabis ingestion. But it's shown that individuals who were admitted to a hospital for high levels of cannabis use were at greater risk for developing a diagnosis of dementia than those who were actually admitted for high use of alcohol. So, it is an important substance to consider. When we talk about the other forms of inhalation, although there hasn't been research that I'm aware of on those various products, it's reasonable to suggest that anytime you're inhaling a smoked or vaporized product that has other chemicals in it, it's going to have a negative effect on your body and it's likely going to have inflammatory effects. So, at least in one of the mechanisms that we likely think tobacco cigarettes are impacting dementia, that's likely true for others, but more research does need to be done. Jay Ingram: Thank you very much for this, Adrienne. It's been really great to have you help us defy dementia. Dr. Adrienne Johnson: Thank you so much for having me. It's been great to talk to you. Allison Sekuler: Thank you. Jay Ingram: Dr. Adrienne Johnson is a clinical psychologist and an assistant professor in the Department of Medicine at the University of Wisconsin School of Medicine and Public Health. She joined us from Madison, Wisconsin. Allison Sekuler: Our next guest has been listening to Dr. Adrienne Johnson. Connor Dorr is a 22-year-old psychology and economic student at the University of Toronto. He works in sales and runs his own landscaping company. These days, he's also a bodybuilder and a triathlete very focused on his health, but that wasn't always the case. Connor started vaping in grade nine, and then he moved on to smoking cigarettes and chewing tobacco. We'll let Connor tell you about his ordeal trying to quit, but eventually, at the age of 19, he did quit. That was with the help of the Nicotine Dependence Clinic at the Center for Addiction and Mental Health or CAMH for short. Connor is now an advisor at CAMH using his experience to support addiction research. Connor Dorr joins us from Toronto. Connor, thank you for helping us defy dementia. Connor Dorr: Thank you guys. I appreciate you having me on. Allison Sekuler: So Connor, when you were listening to Adrienne Johnson and our chat with her, what struck you about that? Connor Dorr: I hadn't taken into account how smoking tobacco products can affect your brain. I thought it was more of a cardiovascular issue and I had no idea of how it actually affects your brain. Jay Ingram: So Connor, can you tell us the story of how your dependency on smoking and nicotine began? Connor Dorr: I would say it started by just trying to fit in. So, in grade nine, I made the football team, but I didn't really feel like I belonged because I was a small kid. One of the guys in the change room offered me a vape, and I'm like, "Oh, okay, I'll try that," and then started to get addicted. Vaping was the big thing and it's super discreet. It just cascaded from there. Jay Ingram: At what point did actually smoking cigarettes enter the picture? Connor Dorr: Well, I started with the vaping and I just hit my friend's vapes in the washroom. Then it got to a point where I bought my own vapes and I tried cigarettes and I was like, "Oh, this is really nice. It's smooth. Let's stick with cigarettes and vaping." But vaping was easier, so I mainly did that. But cigarettes were definitely a presence. If my friends had chewing tobacco or a pouch or whatever, I would use that as well. It was just incessant. We would sit in a friend's basement, watch TV or play video games and vape, and we would go out and maybe smoke some weed. So, we're all together doing it and it's like we're enabling each other. So, it's fine. But it just got out of hand. Jay Ingram: After hearing how deeply you were into it, how and why did you even begin to think about quitting? Connor Dorr: There's three main points. Number one, you mentioned that I was a triathlete and bodybuilder, and I was trying to do more physically active stuff. I was like, "Holy moly, I can't run. I can't do anything. I'm so out of shape," but I've been an athlete my whole life. I'm like, "What the heck's going on?" And then next, my grandfather passed away from dementia, and that made me actually think about my health a little bit more seriously because I was thinking, "Well, he just had the occasional beer as a vice." I was like, "Well, [smoking] is a vice. This could probably affect my life for the worst." But then there was really also a lot of shame, feeling like I had to hide a part of my life from the people whom I love. Because I would remember times where my family would judge my uncle because he's a smoker. He'd go for his "walks" and he'd really be gone for a smoke or something. You'd see that he really was ashamed of it too. I remember I would go on my own "walks" to just smoke or vape, or I'd sit with my window open and try to hide from my parents. I just feel this shame because I didn't want it to be true that I'm someone with such a bad dependency on something and it made me feel like I didn't measure up. I feel like a lot of people feel that, and it's really important to recognize that the best way to get past it is just you have it. An addiction is an addiction. Allison Sekuler: So what happened when you tried to quit? Connor Dorr: That was a bit of a rollercoaster, I'll tell you. First, I got so fed up. I'm like, "Screw this vape." So I tossed it away, got rid of all my paraphernalia, and then I proceeded to shake 48 hours after I quit because I was going through a full withdrawal at that point, but my nervous system was just so not used to not vaping. I was just shaking. It was a very surreal experience. Then I'd be around my friends and you'd smell this cigarette smoke. It's not a good smell, but my mouth would water. Then I'd be like, "Ah, let me try that. Let me try that." Then I would go back on vaping again, and then I'd try to quit again. It happened a whole bunch of times over a year and a half and then you spend all this time beating yourself up or at least I did, thinking, "Well, why can't I do better? I'm weak to this. I have a weakness." It makes it so much harder to actually approach quitting because you feel like there is this giant wall in front of you that is disallowing you from actually achieving what you want. Allison Sekuler: Connor, Dr. Adrienne Johnson said that it's important that we take away the stigma of smoking and indeed recognize that it is a medical condition where people need support. It sounds like that stigma, that shame in some ways locked you into it because you internalized that. You started believing it about yourself, which made you keep smoking. Connor Dorr: I'd say that's completely true and I internalized it. Because I've been competitive my whole life. How could I fall prey to something so simple as this? That's what I tell myself because the shame of smoking, honestly, in my opinion, made me smoke more. It gave me this stress. I'm anxious. I'm like, "Oh, my God, I got to quit. I got to quit." Then I reached out to my doctors and they're like, "Here, go to this CAMH program." Eventually I ended up reaching out to these people. They're giving me advice. They offered all these things, and I'm like, "Well, no, I want to see if I can do it on my own." So they gave me nicotine patches very briefly. I used them for three weeks, and then eventually, I was able to realize that I didn't need [to vape]. I could have it if I wanted to very easily, but I didn't need it to feel okay. That's how I got off completely. Allison Sekuler: So there's certain prescription drugs that people use to help them quit, and our cessation expert is going to be talking about those. It doesn't sound from what you've just said, you've used them. How did you finally quit? You said you could have used them, but you didn't. What did you do? What helped you quit? Connor Dorr: Right. I think you're talking about varenicline. I've actually looked into that quite a bit. It was like a pride thing where I'm like, "I need to do this on my own." But it was also finally being able to get over my shame. I'm talking to my parents. I'm like, "Mom, dad, I am trying to quit smoking. I need support. I'm going to have trouble. I might be irritable. Please help me." Same thing with my friends. I am like, "Hey guys, can you please not vape around me? That would really help me out. I'm really trying to quit." They all did. When I reached out to my support systems and I really just became okay with the fact that I had this shame and got past it, it really, really accelerated my help. Then finally reaching out for that help with CAMH and actually them giving me a good pillar of support. That's what launched me to fully quit. Jay Ingram: You deserve a lot of credit for having quit, but do you think you could have if you didn't have that support? Connor Dorr: That's a really good question. The prideful part of me would like to say, yeah, but I honestly don't think so. I mean, they say it takes a village, and just knowing that I had that support actually really, really was probably the main reason why I was able to stop. Allison Sekuler: When you finally did quit, what do you think it was in addition to the social supports and so on that made it successful? What advice did CAMH give you that was the secret sauce? That's what everyone will want to know. Connor Dorr: They helped me. They gave me nicotine patches initially for just a little bit. I've only used them for a couple of weeks and they also [told me] to reach out to a therapist and practice some type of therapy. I've done therapy throughout my life. Honestly, cognitive behavioral therapy was actually a big proponent where it's like you disconnect your thoughts from your feelings, from your behaviors because the behavior is pretty straightforward, smoking. My feeling is I want to smoke, but my thought is I don't want to smoke. So, you interrupt that feeling from going into a behavior. It's like when you take that step back and be like, "That's not in line with my goal," and you have your support around you [that help you] remember what your goals are [and] I got people cheering me on. Then you have the nicotine patch [that help so that] the urge is not so great. All those little things came together to make it just easy enough for me to break that habit. Jay Ingram: I would say big applause to your friends who agreed not to smoke or vape in your presence. Connor Dorr: Yeah, seriously. Jay Ingram: But there are obviously people you see doing that. I've known people who'd quit for decades and still would happily smoke a cigarette. Do you feel that way? Connor Dorr: 100% yes. No hesitation, yes. People smoke around me today. Smell a cigarette, especially if I've had a bit to drink [and] I'm like, "Oh man, I would love a hit of that cigarette." I would, but I also don't want to. So, I'm not going to. It's practice. You practice not smoking. I know it's against my goals. I'm training for this thing. Actually, that's also something to also mention. I'm always training for something. So, I'm always trying to keep my body in good shape. Jay Ingram: Connor, we really appreciate you coming on the show today and telling your story. Like Allison said, congratulations on having successfully stop smoking. Thanks a lot. Connor Dorr: Thank you. Allison Sekuler: Thank you. Jay Ingram: Connor Dorr is a student at the University of Toronto and an advisor with lived experience at the Intrepid Lab at the Centre for Addiction and Mental Health. He joined us from Toronto. Our next guest knows a thing or two about helping people quit smoking. In fact, he's a world expert on the topic. Dr. Andrew Pipe is the former Chief of Prevention and Rehabilitation at the University of Ottawa Heart Institute. He helped develop the Ottawa model for smoking cessation, a set of evidence-based guidelines that healthcare providers around the world used to support people who want to stop smoking. He continues his work at the Heart Institute, working directly with people trying to quit. He's also an emeritus professor in the Faculty of Medicine at the University of Ottawa. Dr. Andrew Pipe joins us from Ottawa. Dr. Pipe, thank you for helping us defy dementia. Dr. Andrew Pipe: It's a great pleasure to join this conversation. Jay Ingram: Dr. Pipe, you listened to Connor's story. I think it's fair to say he's probably younger than most of our audience, and some who've been smoking cigarettes for many decades might think that Connor's story doesn't apply to them. What do you think? Dr. Andrew Pipe: Well, I think Connor very distinctly outlines some issues which are common to all smokers. First of all, the rapidity with which he became an addict to nicotine. It's the case that once you've learned to inhale tobacco smoke or a vapor, within 48 to 72 hours, the addiction pathways are cemented in the brain and you are now addicted to the most tenaciously addictive drug that we address in our community. He also demonstrated that it takes several attempts to quit and that when you actually reach out and get assistance, the likelihood of cessation is significantly increased. He also reflects a current problem that we have in Canada, that we have the highest rate of teenage vaping in the world. There is considerable evidence to show that teenagers who vape have a much higher likelihood of becoming smokers or continuing their vaping behavior. Allison Sekuler: Now, you used the word tenacious before in talking about the addiction with smoking, and Adrienne Johnson spoke about the addictiveness of nicotine comparing it to heroin. Do you have anything to add to that description? Dr. Andrew Pipe: Very accurate description. If you inject a drug into a vein, it takes 14 to 20 seconds before that drug reaches the addiction centers in the brain. When you inhale anything, it's delivered via the pulmonary, the lung circulation directly to the heart, where it is almost instantly pumped out through the arterial circulation and reaches the addiction centers of the brain in four to five seconds. The rapidity of delivery of an addictive substance is a powerful determinant of just how addictive that agent will be and the difficulties that individuals might face in addressing it. Allison Sekuler: Connor talked about his efforts of quitting cold turkey. How difficult is it to quit cold turkey, and do you have any measure of the success rate there? Dr. Andrew Pipe: Well, we do know that overall, if you look at the total population of people who were former smokers, the majority of that group will have quit cold turkey. Of course, that involves individuals who quit before cessation aids became available. So, it's important to recognize the power of the cold turkey approach. But here it's important also to underscore something which was noted by Dr. Johnson, and that was one of the most important predictors of smoking cessation success is the number of times somebody has made a quit attempt previously. So, one should never quit quitting. But I think the great breakthrough, if I can use that term today, is that we now know that using cessation pharmacotherapies appropriately can very dramatically enhance the likelihood of smoking cessation. Allison Sekuler: Connor also talked about vaping as being very addictive. Is there anything to be said for vaping being less harmful to our bodies and brains than tobacco? It was initially put forward as harm reduction, wasn't it? Dr. Andrew Pipe: Well, in one sense, yes, because combustion is not involved in preparing that vapor. There are no products of combustion, which are carcinogens. On the other hand, the liquid, which is superheated in the electric reactor, which is the vaping device, produces volumes of vape, huge quantities of an array of chemicals, many of which interact each with the other, and levels of nicotine, which would never be possible to administer using a combustion product. So, individuals who vape get massive quantities of nicotine. Because vaping devices are used in a different fashion than cigarettes, a typical cigarette smoker takes a drag, parks a cigarette in an ashtray for a minute or two, takes another drag. Vapors tend to be sucking on it in a more or less continuous fashion. So, they get staggering amounts of nicotine, which further cements the addiction. The likelihood of individuals who use vaping devices to stop smoking is very low indeed. In fact, more commonly they become what we call dual users. They smoke cigarettes and they also use vaping devices, which further complicates the cessation process as you can well imagine. The other reality is that the evidence is now occurring that the thousands of chemicals that are present in vapor have themselves carcinogenic properties and have [an impact] on the cardiovascular system, which of course is of specific interest when we talk about dementia. I would predict that in the decades to come, we're going to face an onslaught of vaping-caused disease, particularly lung disease, and all of the other manifestations that occur when you inhale a toxic stew of superheated chemicals. Jay Ingram: So the most important thing we're really addressing here is stopping. What do you think, Dr. Pipe, is the most important thing people need to know about quitting smoking or vaping? Dr. Andrew Pipe: I think first and foremost, help is available. That help can come from many places in many forms: public health units in Canada, family physicians, smoking cessation clinics and hospitals. We've made the point in our work that responsibility for smoking cessation assistance resides with every clinician who sees patients who are smokers. First and foremost, it's important to ensure that the messaging that we give to smokers is one that relates and reflects that we understand how difficult smoking cessation can be. That we're here and prepared to provide assistance and will always offer that assistance. It can be much more sophisticated than in the past in terms of the way in which we dose that assistance and the duration for which we use that cessation pharmacotherapy. So, we can distinctly improve the likelihood of smoking cessation success. In our clinical settings, we can show 40 to 60% smoking cessation success, biochemically validated six months after making a quit attempt. If you will, let me suggest what is an ideal message that smokers should be receiving from healthcare professionals? [For example:] Jay, I see that you're still a smoker, and given that we're managing your lung disease, it's just so important that we help you with this. I'm sure you've probably struggled with this in the past. Please know we're here to help and don't ever hesitate to ask for our assistance. Similarly, when you're speaking to family members, it's important to understand that you appreciate that this is a very difficult process for many people and that you also understand that they may be irritable or grumpy and you're going to do your best to assist them as they make this very significant attempt to dramatically improve their health. Jay Ingram: There are prescription drugs that at least are claimed to help people quit. How effective are they? Dr. Andrew Pipe: They're very effective, and they have completely transformed our ability to help individuals stop smoking. So, nicotine replacement therapy, which is the bedrock of cessation pharmacotherapies, if you will, is available without a prescription. Unfortunately, it's been used poorly by both clinicians and by smokers themselves. In part that's because the initial messages surrounding these products said, "Use this product in this way. Take a patch of this dose for a couple of weeks and then replace it with a lower dose and then replace it with a further lower dose." Well, if you're still smoking after that, go away and think more carefully about when you're prepared to make a cessation attempt. Rather than understanding that as in any other area of risk factor modification, we need to titrate the dose and prolong the dose until we get an appropriate response. We're going to ask you to use a gum or a spray or a lozenge throughout the course of your day if in fact the pressure to smoke becomes more intense. We're going to persist with that for as long as it takes as you acquire a whole new repertoire of non-smoking behaviors and you yourself sense that you can safely throttle back, if you will, on that particular dose. The single most effective pharmacotherapy for smoking cessation is a combination of nicotine replacement therapy, the patch, which provides a background level of nicotine supplemented as needed with a more rapid form of delivery such as the gum or the spray. The most effective single agent is varenicline, and this is a great aid for smoking cessation. Allison Sekuler: When Connor was talking about quitting, he also talked about the stigma and how he felt guilty and weak because he couldn't quit. You've touched on that as well. In your work with people who want to quit, how big a role does stigma play in helping or hindering them? In other words, people are not thinking that it's a medical condition, but just thinking someone is weak or a bad person for smoking. Dr. Andrew Pipe: Yeah, I think smokers who've made quit attempts and failed are very judgmental of themselves, and I think it's important particularly for health professionals to understand that the overwhelming majority of smokers know why they shouldn't smoke. A vast majority of smokers will make one or two personal private quit attempts each year, 95% of which will fail, which further cements that sense of failure and self-stigmatization. But it also underscores why as healthcare professionals and others, we don't have to educate smokers. Providing reason number 279, why you should stop smoking is not going to be really helpful, as opposed to providing them with understanding, support, and specific assistance. Now, I would roll back that concept a little. Most individuals who think of smoking and health think of lung disease. They don't know about the fact that most smoking-related deaths are not cancer, but are cardiovascular. Of course, the vast majority of the population I would suspect until this point, has no idea of the dramatically enhanced risk of dementia that comes with smoking. I think that's a very powerful message that we should be speaking about because many in the community as they think about their own health and the things that they would steadfastly like to avoid, dementia would be at the top of many of those lists. Jay Ingram: Dr. Pipe, we mentioned in the introduction to this interview the Ottawa model for smoking cessation. Could you give us a quick description of what that is? Dr. Andrew Pipe: Yeah. It was originally designed to be administered in our setting at the University of Ottawa Heart Institute, and it meant that we would introduce a very specific protocol. It meant that every patient who was admitted had to be asked about their smoking status. Surprisingly, if you go to most Canadian hospitals and ask, "How many of your patients are smokers?", they can't tell you. So, it mandated that the smoking cessation status had to be documented. When that was documented, it triggered the delivery of an offer of assistance, such as I modeled in that conversation a few moments ago. That offer of assistance was accompanied by the provision of nicotine replacement therapy, and we were able to show that we were able to dramatically increase the likelihood of smoking cessation amongst our patients. We replicated that in other hospitals, the same conclusion, the same story. So, now that the Ottawa model has been adapted to be delivered in cancer clinics, orthopedic clinics, specialty clinics, primary care settings, hospitals, and it's being administered around the globe. It's all about doing ordinary things extraordinarily well in a very sensitive and supportive manner. The even more important evidence that accrued sometime after we had administered this is that we could demonstrate a dramatic reduction in hospital readmissions, emergency room visits, and all-cause mortality. Particularly when we're dealing with diseases which are tobacco or smoking-related [like] respiratory disease, cardiovascular disease. Hospital readmissions are frequent and they're very expensive. So, we can produce dramatic and distinct savings for the healthcare system as well as dramatic improvements in people's health and long-term life expectancy. Allison Sekuler: Well, thank you so much for joining us today with so much great information and food for thought. Jay Ingram: Yes, thank you. Dr. Andrew Pipe: It's a pleasure to have been a part of this important conversation. Thank you for the compliment of the invitation. Allison Sekuler: Dr. Andrew Pipe is a researcher, a physician, and an emeritus professor in the Faculty of Medicine at the University of Ottawa. He joined us from Ottawa. Jay Ingram: Wow, Allison, there's a lot of really interesting information and new information as far as I'm concerned. I had no idea that nicotine, once it gets into you and into the brain, triggers the addictive mechanisms, not in hours or days, but in seconds. It's already known from other research that when you look at the addictive power of nicotine and compare it to other well-known addictive drugs like heroin, they're pretty much comparable. This was all news to me. Allison Sekuler: I also thought it was really interesting when Dr. Pipe said, "You should never quit quitting." Really highlighting some of what we heard in Connor's story about trying to quit multiple times, but also the hope related to that. First of all, there are these new cessation methods that you can use and Connor talked about cognitive behavioral therapy, but also the pharmacology, the drugs that now are in play that are so much better than they were years ago. There are ways to quit when people can get over that stigma and have the support from their family. The other thing I thought was really amazing was the hope that Dr. Adrienne Johnson shared with us about how forgiving the brain was, even if people have been smoking for a long time. In as little as three years, their brains could recover to the point as someone who didn't even smoke. We always say it's never too early or it's never too late. This is a really great example of that. To find out more about how we can all boost our brain health and reduce risk of dementia or slow its progression, please visit us at defydementia.org. There you can check out other episodes of the podcast as well as our videos, infographics, and other resources, and we'll also have some resources on how you or your loved ones can quit smoking. Jay Ingram: For healthcare professionals who are interested in learning more about the Ottawa model for smoking cessation, which Dr. Andrew Pipe helped create, we'll have a link there for that too. Allison Sekuler: Our podcast production team is Rosanne Aleong and Sylvain Dubroqua. Production is by PodTechs. Music is by Steve Dodd. Our cover art is by Amanda Forbis and Wendy Tilby. Our writer and Chase producer is Ben Schaub. Jay Ingram: For their advice and help, we'd also like to acknowledge Dr. Peter Selby and Dr. Stuart Matan-Lithwick at the Intrepid Lab at the Centre for Addiction and Mental Health in Toronto. A big thank you to both of you. Allison Sekuler: And we'd also like to thank the funders of the podcast, the Slaight Family Foundation, the Centre for Aging and Brain Health Innovation and Baycrest. Jay Ingram: And of course, we're very grateful for your support too. So, please click that subscribe button for Defy Dementia wherever you get your pods, and don't forget to leave a like, a comment, or maybe even a five-star review. Allison Sekuler: Next time on Defy Dementia, we'll have a show you can really sink your teeth into. We're going to be looking at oral health and dementia risk. It turns out there's actually good evidence that oral infections like periodontal disease can increase our risk of dementia. Jay Ingram: It's the kind of show that might have you reaching for dental floss. Allison Sekuler: But seriously, this is a show for anybody who has a brain or who also has teeth and gums. So, don't miss it. I'm Allison Sekuler. Jay Ingram: I'm Jay Ingram. Thank you for listening to Defy Dementia. Don't ever forget, you're never too young or too old to take care of your brain.