Better Now than Never: Quit Smoking to Reduce Your Risk for Alzheimer’s Disease

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Dr. Nathaniel Chin: I'm Dr. Nathaniel Chin, and you’re listening to Dementia Matters, a podcast about Alzheimer's disease. Dementia Matters is a production of the Wisconsin Alzheimer's Disease Research Center. Our goal is to educate listeners on the latest news in Alzheimer's disease research and caregiver strategies. Thanks for joining us.

Welcome back to Dementia Matters. I'm here with Dr. Adrienne Johnson, a postdoctoral fellow at the University of Wisconsin Center for Tobacco Research and Intervention. Her research focuses on understanding why some groups of people struggle to quit smoking cigarettes and developing smoking cessation programs for these difficult-to-treat populations. In April 2021, the Wisconsin Alzheimer's Disease Research Center granted Dr. Johnson a developmental project award to support her work to help older adults quit smoking. Today on the podcast, we are going to discuss the link between cigarette smoking and Alzheimer's disease and Dr. Johnson's work to develop a program to encourage older adults to quit smoking. Dr. Johnson, welcome to Dementia Matters.

Dr. Adrienne Johnson: Thank you so much for having me.

Chin: Let me start by asking what sparked your interest in studying the effects of cigarette smoking and particularly how it affects cognitive decline?

Johnson: Well, as part of my training to become a clinical psychologist, one of the things I did was cognitive testing. And the area I did that in was for people who had a diagnosis of epilepsy, meaning they were having regular seizures and their epilepsy was uncontrolled, so they were determining if they were eligible for a brain surgery as part of a treatment for this. And when doing that cognitive testing, the discussions I had with these patients really highlighted that they were also dealing with substance use particularly tobacco use, as well as other mental health issues. And it became clear to me that this was a really common issue in this population but one that wasn't commonly discussed. So my dissertation work was actually on the impact of tobacco use on their seizures and what I did was - we looked at current smokers versus people who are not currently smoking and found that current smokers were four times more likely to have had a seizure in the past year. In doing this work, it just became clear that there are many things that can be done to help your brain health and to prevent cognitive decline that are less severe than potentially a brain surgery which really was important for this population, but that's how I got into it. And one comment I wanted to make is that I have since transitioned from a postdoc to an assistant scientist at the Center for Tobacco Research and Intervention and I'm really excited to continue this work.

Chin: Well, congratulations and thank you for correcting me on that. It's a big step.

Johnson: Yes, thank you! 

Chin: And I love that it was your clinical experience that really fostered this important research that you're doing but really gave you a specific focus.

Johnson: Yes, yes, I felt so fortunate to have that training. I'm trained as a clinical health psychologist but I really just - I love the brain. I love the importance of it. I love that that's what makes us tick, and unlike other areas of health - heart health, lung health - the impact of tobacco and cigarette smoking on the brain is one that hasn't been discussed nearly as much. And that's kind of where my career has led and is leading to - to focus on how does smoking impact brain health.

Chin: Well then let's get to it. So what are the effects of smoking on Alzheimer's disease risk and/or general cognitive decline?

Johnson: Sure. So individuals who are current smokers are up to seventy percent more likely to develop dementia. And as we know Alzheimer's is a form of dementia, so there's also an increased risk for developing Alzheimer's disease specifically. We also know that within as early as three years of quitting the risk of overall dementia can be comparable to that of a never smoker. And then if we look at Alzheimer's specifically the research has shown that within eight years of quitting, your risk of Alzheimer's can be comparable to someone who's never smoked. That is even as we age. I really like to highlight - that's not just when you're really young. Obviously there's a benefit to quitting earlier, but doing so at any age can really help your health.

Chin: Wow, okay, so just so I can recap that. When it comes to dementia - which is more of the broad cognitive decline and functional decline - if you quit three years or more ago, you're at roughly the same level of risk as if you had never smoked.

Johnson: Correct. You're, as we would say scientifically, not statistically significantly different, at our mumbo jumbo. But I think it's exciting to know that as early as three years, that can be the case. And then for Alzheimer's disease, it takes a little bit longer for that eight year period to be comparable to a never smoker.

Chin: And why do you think that is? Why the difference between Alzheimer's and then dementia?

Johnson: I think that is a great question. I think that one of the issues I'm hoping to work more on is that we have less research looking at smoking and Alzheimer's disease specifically. A lot of the time when we think about smoking we think about vascular dementia, which makes sense. We think about smoking and the heart. And what I really aim to find out is the direct relationship or the mechanism at which smoking or tobacco use impacts Alzheimer's disease specifically. Because that is so important to our generation, older generations, as my parents and others are dealing with the effects of aging.

Chin: Well you kind of stole my next question, Dr. Johnson. So - because you have done work already on smoking as a risk factor for Alzheimer's disease, are there other things that you can share with our audience about what you have found with your - already your preliminary studies?

Johnson: So one of the studies that we did was, we looked at the impact of smoking on eventually developing dementia as well as the risk for death and the risk for death following dementia. And if you think about smoking and what the world already knows, people who smoke are at greater risk for dying, unfortunately. It impacts almost every organ in the human body. But we also confirmed that when looking at the Alzheimer's data from across the country using the NACC dataset - which I'm sure you can speak to better than I can - that people who were smoking, were current smokers, were at greater risk for developing dementia, even when we had already taken out that risk of death as well as agreater risk for dying after dementia. So it's not just, “Oh, I'm afraid that by smoking I'm going to die.” It's going to impact, potentially, your quality of life, your likelihood of experiencing dementia and cognitive decline, and one of the things that we are looking at was nursing home placement as well, because that's a common issue associated with dementia.

Chin: I think that's a pretty profound finding because what you're describing is the experience living with dementia, the course of having dementia, and perhaps - and I'm only speculating - almost the rate of decline once you have dementia, which would make sense because smoking increases inflammation and vascular disease. All these things could have a factor.

Johnson: Exactly, yes. I think that's a great description. One of the areas that I hope to look into is kind of that timeline piece. When upon quitting might we see a change in terms of Alzheimer's risk and then decline towards other health issues and eventually unfortunately death? But yeah, it's something that impacts your life throughout your life and that's why I'm particularly interested in it.

Chin: I find this finding of yours, of smoking recency - as I think I've read in your publications - I mean, it's very compelling but it's also hard for me to believe, truly, that your whole like your middle life, you could have smoked a ton and that doesn't have its effect later on if you stop smoking. I mean, in essence you haven't found a quantity relationship.

Johnson: Right. And that's contrary to what's been found previously, so I want to note that. Other research has found a quantity or a dose response relationship. What's commonly used to quantify smoking is pack years, so how many packs per year you've smoked throughout your life. What we found when we were using more of a complex model that took into account death as well as dementia prior to death and trying to look at that timeline a bit more was we found that more had to do with recency then quantity. So we basically controlled, statistically, for pack years and that was one that didn't come out as a significant factor. I think that, to me, that's motivating because it really says, “Okay, I can still make a change. I can still have an impact.” And that's what I like to highlight to people is that you can still do something really important now.

Chin: I think that's incredible. I think that has a huge clinical relevance for people to know that - yes, what's happened in the past is in the past, but if you're willing to quit now and for the next few years, there's going to be that kind of gray zone but then you're really going to be back to that risk that you were before of having not smoked.

Johnson: Exactly, and even in that gray zone in terms of dementia - which is obviously the focus of what we're talking about - I think it's important to remember there are some really quick changes. Within twenty minutes of quitting, your blood pressure drops. Within a day your heart attack risk decreases. It goes to half within a year. Your risk of stroke is comparable to a non-smoker within 5 years; heart attack within 15 years. So things that we know impact dementia risk are all happening throughout that time. And the things that you're dealing with in your day to day are also really quick. I like to highlight anxiety and mental health changes that happen from quitting as well because that's one of the main reasons people discuss why they smoke.

Chin: It's a huge benefit for the whole body, in essence. 

Johnson: Yes. For the whole body, yes.

Chin: Well, now you've also done work on how smoking does impact communities in a different way or there's more disadvantaged communities that might be suffering from tobacco use compared to others. So can you speak to that?

Johnson: Yes, so one of the areas that I am focusing on with the funds provided by the Wisconsin ADRC is developing a culturally specific motivational intervention for African American older adult smokers. And the reason I'm focusing on this group in particular is that, as you know, African Americans are at greater risk for developing Alzheimer's disease. But also they are more likely to experience the negative health effects from smoking, and that is across the board including death, mortality, as well as dementia. They have unfortunately been targeted by the tobacco industry since the beginning of tobacco and that is shown in greater advertising in areas that are more populated by African American individuals, use of mentholated cigarettes and targeting towards that African American population. And mentholated cigarettes are - thankfully there was a recent change and they've been banned -  but they are more addictive and they are problematic in that by being more addictive they cause more health issues and are harder to quit. So not only are they - are African Americans more likely to have the negative health effects from cigarettes, they're also more targeted and for those reasons we really want to focus on developing a tailored intervention for this particular population.

Chin: Well, it's horrible and that makes a lot of sense. I'm glad you're working on this, Dr. Johnson.

Johnson: Yeah, thank you.

Chin: And so, but now from - and including the African American community but really all the communities, how can caregivers and/or family motivate or support current smokers so that they can quit?

Johnson: That is a great question, and the first thing I would say is to use evidence-based treatment. So for quitting smoking, the first thing is to identify a quit day. So I should take a step back. If we're talking about somebody who is your relative, your family member, keeping in mind that nicotine is a hard thing to change and it is something that will be difficult. The first thing is to motivate, to help an individual see why they might want to quit. What are the reasons that smoking is difficult for you? And there are also going to be reasons why you'd like it - and acknowledging that and letting that be okay, but highlighting the benefits of quitting. Setting that quit date, having a specific date in mind and planning for it, and then - in line with planning for it - using whether it be nicotine replacement therapy - and that comes in the form of a nicotine patch, nicotine gum, there are lozenges and other things. I've heard for older adults, the gum can be problematic because of dentures, so focusing on other forms, as well as certain medications like varenicline and bupropion.

Chin: Is there a difference in a population that already has cognitive impairment? Do you have different strategies that we might employ to support those individuals?

Johnson: Yeah, so there's been really very limited, if any, research on how to help people who are already cognitively impaired quit smoking, so I'll put that statement out there. But thinking along the lines of, how we could best help? Again, making sure that we're providing the medication to help with the withdrawal symptoms, making sure that we are being supportive in the same way that we would be with any other health behavior change, planned for it but - given that planning can be harder if you're dealing with cognitive impairment - providing that plan in a way that you can support. So, “Okay, I know that today is dad's quit day. He might be a little bit more irritable today. He might have a little bit more difficulty. He might just feel that way and that's okay.” Remembering to remind him, “Okay he needs to put on his patch this morning. I'm going to make sure he puts his patch on. Just one, and that he does a new one tomorrow.” Things like that that you might already be doing to support your loved ones who are dealing with cognitive decline help them make those changes. And then the other piece for smoking is again, similar to other health behavior changes, it's a process. It takes time and it can be difficult as you get through those first couple weeks. Usually the first two weeks are the most difficult in terms of withdrawal symptoms, but being supportive throughout that change. Clearing out cigarettes from the home. If you yourself also smoke, ideally try to quit as well. If that's not the case for you, then at least refraining from smoking around that person who's really trying to quit because it's hard when you see someone else do something that you are trying to stop. And then, rewarding yourself. That's something we really want to highlight. As you make it through those processes and get to those places of, “Oh I've been a week. I've been 2 weeks.” That's great! Give yourself some credit. Whether it be, you know, going to a nice movie - once those open up again - or it, you know, having a nice dessert. You deserve rewards to get through this big change because it really does - it does help you in every way.

Chin: I'm glad you mentioned getting the cigarettes out of the house because one of the things that I've been talking with my patients and family members about is that if the patient is ready to quit, sorry but so should the family members who are in the household. And I try to get them to do it together so that is a process done together, so that makes sense too then.

Johnson: Yeah, and that's so wonderful to hear that you are encouraging that within your patients. I think it's something that can be motivating in, “I'm not just doing this for me. I'm doing this for me and my loved one.” And at the same time respecting that if you are struggling, try, try again. It's okay. Use it as a learning experience, see what got in your way this time, and move forward. So not only getting that out of your house but figure out, problem solve. “Well what got in the way? Oh I was around another smoker. Oh, I drank a little bit.” A lot of times alcohol can be what brings people back to smoking cigarettes. So finding that quit day, setting it. We like to, in the medical field, use the 5 A's to kind of keep that in mind. Sometimes we even just shorten it to be less than five and go to just - ask, advise, arrange, and assist. So we want to ask “Are you smoking?”, advise you to quit, arrange for support and assist as they get through that. It's really something that we can all do to help the people we love.

Chin: So then, going back to your research, I can hear the passion in your voice. What are you looking to study next after completing this project with the Wisconsin ADRC?

Johnson: So what I hope to do is to develop a motivational intervention that can motivate older adults to make quit attempts and to use evidence-based treatment. Once we can do that, we can get these older adults in the quit process and, ideally, be successful because we know for older adults when they use that evidence-based treatment, they're actually more successful in quitting than younger counterparts. So something exciting to keep in mind. I would like to examine the impact of smoking cessation on Alzheimer's disease biomarkers, whether they be blood-based or CSF-based, as well as just general brain health, neural degeneration. And I'm really interested in looking at how soon after quitting might you see a change in your brain health. And to look at that in a very mechanistic way, is something I really look forward to.

Chin: And that sounds very exciting. And so I guess to end today, can you share some resources where listeners can get help or stop smoking, or where they can even just find the resources for maybe their loved one who's currently smoking?

Johnson: Yes, I'd be happy to. So the first resource I will share is 1-800-QUIT-NOW. Q U I T N O W. That is a national smoking cessation quitline, and in Wisconsin they can provide you with free evidence-based smoking cessation medications as well as a free coaching session to help you quit. In each state what they can provide is different but it exists in every state. And the other thing I will say is smokefree.gov. That is a website that can be accessed by all and it has different specialty populations you can look into. It also has access to different apps that you can use - mobile apps - so those would be the first two. The other that I would always say is to talk to your primary care provider. They can prescribe medications to help you quit and see what they can do to get you that support whether it be counseling medication or just helping you plan it out.

Chin: Well thank you again, Dr. Adrienne Johnson, for being on Dementia Matters and sharing this very important and quite interesting research.

Johnson: Thank you so much for having me. It's been a pleasure.

Outro: Dementia Matters is brought to you by the Wisconsin Alzheimer's Disease Research Center. The Wisconsin Alzheimer's Disease Research Center combines academic, clinical, and research expertise from the University of Wisconsin School of Medicine and Public Health and the Geriatric Research Education and Clinical Center of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. It receives funding from private university, state, and national sources, including a grant from the National Institutes of Health for Alzheimer's Disease Centers.

This episode of Dementia Matters was produced by Rebecca Wasieleski and edited by Caoilfhinn Rauwerdink. Our musical jingle is "Cases to Rest" by Blue Dot Sessions.

To learn more about the Wisconsin Alzheimer's Disease Research Center and Dementia Matters, check out our website at adrc.wisc.edu. You can also follow our Facebook page at Wisconsin Alzheimer’s Disease Research Center and our Twitter @wisconsinadrc. If you have any questions or comments, email us at dementiamatters@medicine.wisc.edu. Thanks for listening.