Interview with Richard Pruen on the Links Between ADHD and Nicotine

October is ADHD Awareness Month. While the neurodevelopmental disorder has made its way into the public consciousness more than ever, it’s still frequently misunderstood.

Being diagnosed and getting treatment for ADHD can change people’s lives by improving their focus, organisation, and self-control. However, much of the medication used to treat the disorder can be quite harsh, leading to unwanted side effects for some, such as insomnia, loss of appetite, increased anxiety, and mood swings.

There is a vast body of research that shows how nicotine works to alleviate the symptoms of ADHD. So, who better to discuss it with than the charming Richard Pruen, founder and custodian of the incredible Safer Nicotine Wiki?

In a wide-ranging conversation, we talk about how Richard successfully treats his ADHD with nicotine, why the stimulant is not more widely prescribed as a condition by the medical community, NHS ADHD diagnosis waiting lists, why many of the current ADHD treatments suck, and a whole lot more.

Early discovery

One of the most interesting angles for me is how you first realised that nicotine was helpful for your ADHD symptoms.

I guess that was when I was ten years old. I picked up a cigarette that somebody else had half smoked, took a few puffs, and suddenly, I could think in straight lines. It was that profound. So, I immediately went to the nearest tobacconist, which was around 100 yards from the school, and I bought 10 Embassy Number 4 because they were the cheapest pack I could get.

I didn’t even know that ADHD was a thing until I was in university. So, for you at that age, you obviously didn’t have a label for what you felt?

No. There were some signs that something wasn’t quite normal. I can go through my medical records and see that in 1983, they called it incoordination or something. It was before autism, ADHD, or anything like that was ever diagnosed. It was basically unheard of, but something was noticed.

So, how heavily did you start smoking, then?

I pretty quickly went from Embassy Number 4, which was unfiltered Virginia Embassy tobacco, to Capstan full-strength, the strongest cigarette available. They had 3.14mg of nicotine per cigarette, while I think the Embassy Number 4 had 1.3mg.

Straight into your 10-year-old lungs, as well.

Yeah, but I don’t think that I’d have made it through college if I didn’t smoke. It was that profound a change in just being able to focus on something.

That’s incredible, isn’t it? And what did your parents think of this arrangement?

Well, they both smoked. As long as I wasn’t stealing theirs, they didn’t seem that concerned.

That seems reasonable.

Adult diagnosis and ADHD treatments

So, when did you understand what you were dealing with?

I didn’t really discover what it all was until, at the age of 48, I was diagnosed with what was called at the time Asperger’s Syndrome. They now call it autism spectrum disorder plus ADHD.

Right. So you have this 38 years where you were self-medicating?

Well, I discovered that nicotine worked when I took up vaping in 2007. I started vaping seriously in 2008, but only in situations where I couldn’t light up a cigarette. By early March 2009, I’d quit smoking by accident. The way I noticed was that I had money in my bank account that I’d budgeted to spend on cigarettes, and it was still there.

Around 2010, I tapered down nicotine, thinking, well, I’ll just stop vaping. And then it kicked in that nicotine is actually useful; it’s doing something.

That’s fascinating.

Then, and I’ve no problem mentioning this, but I have paranoid schizophrenia. I was actually hospitalised with it in 2016, and at that point, I’d tapered down and stopped vaping and tried the prescribed ADHD meds.

The least bad one was Adderall, but it’s quite rare for it to be prescribed in the UK. The UK-approved ones were terrible, to the point where they were giving me diazepam and lorazepam as PRN (as and when required medication) for anxiety.

So then, I had a bit of a tussle of having daily diazepam and then trying to stop using it. The withdrawal symptoms from that were just horrific. If you get really stuck into it, it can actually kill you.

What about Wellbutrin? A friend of mine with ADHD didn’t want to take any of the more addictive medications, so he was recommended that. But I also hear that it’s a stop-smoking aid as well, which is quite interesting.

That isn’t really used over here.

Oh yes, he’s in Germany.

There’s some stuff called Lisdexamfetamine, which is still a stimulant, but it’s a prodrug that your liver converts into the actual stimulant. They reckon that would be less problematic, but for me, that was far worse than dexamphetamine, which was also really bad.

Like I said, Adderall was the least bad, but I’d rather not take any of those because I don’t get on with them. They work for what they’re supposed to do, but if you have to take benzos daily because of the side effects? Let’s not do that.

Yeah, benzos just cleave a bit too much of the self out of the picture. I do wonder about the overprescription of meds for young boys who are considered a bit unruly. Is that a legitimate concern?

At least in the UK, you have to go through a reasonably rigorous diagnosis procedure for ADHD. You have to have attention problems, and they have to be present from a very early age. They interview parents and all that kind of stuff to get a background.

These mediations are not just handed out because they say, “Oh, this child is a bit disruptive, let’s call it ADHD.” That doesn’t really happen. The autism one is the same. To get diagnosed with autism, they have to go back through your school records and find the signs and stuff in there.

NHS diagnosis waiting lists

I was researching the NHS ADHD diagnosis waiting list, and they were saying that it can be anywhere between five weeks and five and a half years for kids, and for adults, they were saying that someone was waiting ten years in Wales!

Yeah, the problem is that it’s so exhaustive that they have to go back to your school records to find the signs. So, they have to request your school records and go through your medical records. Luckily, with the NHS, everyone’s records are available. But, if they’re not the electronic ones, and they haven’t been digitised, then they have to request paper records from the surgery.

Yeah, that’s a lot of friction for people who need some relief.

It can take a long time, and somebody has to review all of that material, interview the patient, and then decide if they meet the criteria or not. So there’s a heck of a lot of work that goes on in the background.

I remember being diagnosed as an adult. They spoke to my mum and went back over my childhood. Sadly, she has dementia now, so she probably wouldn’t remember a lot of this, but they had to find the signs in reports from school. They look for key behaviours. Quite often, they’re easy to find when you’re looking for them, but it just takes time.

They need these records because the condition has to be present from birth because there are dopamine conditions and neurodegenerative things that can kick in later in life, and they have to rule those out as well.

For me, it took about three and a half months.

I guess that’s quicker than the average. But for some cases, I worry that these could be really pivotal months or years for someone’s education.

Usually, if there is a big problem, they’re put on the higher priority stream. The people who are borderline — or who are self-diagnosed — tend to be on the longer waitlist if, for example, they’re not suffering from issues at school or work.

OK, that makes a lot of sense.

How do you feel about your situation now? Do you feel that you’ve got it under control with nicotine?

For me, nicotine works absolutely perfectly fine as a treatment, and it doesn’t have horrible side effects like massively amplified anxiety. Having autism, you get social anxiety anyway.

If you have something that helps you focus on tasks and not be completely scatterbrained but gives you horrible anxiety, that’s not really helpful. Nicotine actually reduces anxiety as well. It’s the only stimulant that I can think of that does that.

Yeah, that’s so incredible. I can’t think of one either. Actually, just thinking about stimulants gives me tightness in the chest.

Industry roadblocks

I think I know the answer to this, but I’d love your perspective. Why aren’t people speaking about nicotine more as a possible treatment for ADHD? Why don’t we have doctors and industry people researching and recommending it?

Well, there is a decent amount of research. There is a page on the Safer Nicotine Wiki that has hundreds of studies, at least. So, it has been looked at. The problem is that the people in tobacco control won’t accept that nicotine has any benefits to anybody.

So much time has been spent demonising nicotine because it was the thing that kept people smoking. That’s why a lot of people think that nicotine causes cancer when it doesn’t.

Yeah, there is just this thicket of misinformation that has been decades-long in the making that it makes it hard to correct the record.

But it just seems like quite an elegant solution to that problem, and it’s a shame that more people aren’t aware of its potential.

There is a nearby autism spectrum service that I attend. They’re well aware that people with high-functioning autism or ADHD+ tend to react more strongly to medication.

They seem to recommend the grey import nicotine patches from China which contain around 93 mg of nicotine.

Wow!

These patches don’t deliver 93 mg of nicotine at once; it’s over 24 hours. The highest nicotine patches you can get here are 21 mg over 24 hours.

So, there is some threshold where it starts being effective as a treatment. Is that based on individual physiology?

Yes. Everybody is different. That tends to be what they recommend there, unofficially. So, try the 21mg first, and if that’s not effective, they say order from China. Or, of course, try oral nicotine pouches or vaping, both of which are popular there.

They’re quite happy for people to vape. What they do say is don’t take up smoking because although it will help, it also kills you.

Yeah, I think I’ve seen some tobacco control types attempt to float the idea that nicotine causes ADHD.

It’s associated, yes, because people with ADHD, whether they know it or not, self-medicate with nicotine because it works. So, for a large majority of people with ADHD, it works fine. For some people, it isn’t as good as the medications that they are prescribed, but for most people I’ve come across, nicotine is effective.

For people with ADHD combined with autism, nicotine seems to be the only thing that really works without causing serious problems that need benzos every day.

Yeah, so even that. Let’s say we’ve got a boy, he’s 14 or whatever, and he gets a diagnosis, so he’s put on Ritalin, and he’s got to take benzos. So, what’s that going to do to his liver or kidneys in 50 years’ time?

It’s more a problem of if there is ever a problem getting the benzos. Then, you’re going to have to go through the withdrawal symptoms of the benzos but also stop taking the Ritalin.

That’s brutal. It’s refreshing to know that some ADHD and autism services are taking a more pragmatic approach.

The NHS are quite good at recognising that nicotine is helpful for a number of things, including schizophrenia. Two years ago, 80% of people with schizophrenia smoked. It’s down to about 40% to 60% now, but it’s still massively higher than the general population.

I’m guessing that a lot of them have transitioned to pouches, patches, or vaping.

Yeah. That’s something which I’ve been involved with, at least for the Avon & Wiltshire Partnership Trust. I got involved as a patient representative, and it went as high as the Trust’s manager meetings. I ended up with them making sure there were at least at-cost disposable e-cigs in the clinic.

So, if someone turned up as a smoker, they could buy a disposable without any questions asked, which meant they didn’t have to go offsite to buy cigarettes or go without.

At the moment, I’m also part of a group that is funded by ASH UK, which is working on trying to improve the situation further in both outpatient treatment and community mental health to try and help people find an alternative to smoking.