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Written by guest author Dr. Larry Kaskel

In the high-stakes world of aviation, where precision and focus are paramount, aeromedical examiners play a crucial role in ensuring pilots are fit for the skies. As a certified FAA aeromedical examiner myself, I've found that adopting a nuanced approach to nicotine use benefits pilots as it is a safe alternative to smoking or vaping and can even lead to performance enhancements in the sky.

In my practice, I actively encourage pilots to consider Nicotine Replacement Therapy (NRT) as a viable option while in the air. This recommendation stems from my belief that NRT provides a safe alternative to both vaping and smoking. Unlike pharmaceutical enhancements (such as stimulants, Adderall, Provigil, or illicit substances), NRT presents minimal risks to pilot performance and mitigates the uncomfortable nicotine withdrawal symptoms that can affect flight performance. In my opinion, NRT assists in securing a fully optimized pilot in air.

Contrary to popular belief, nicotine itself isn't the enemy. The negative reputation is due to the 500+ harmful chemicals found in cigarettes, rather than nicotine. Critical to understanding the impact of nicotine is separating nicotine from its toxic companions and recognizing that, when used in moderation, nicotine does not pose significant threats to one's health. Living in America, it’s clear that this country has a far greater addiction and reliance on caffeine than it does nicotine. In my medical opinion, nicotine and caffeine are similar in their stimulant effects. It's my contention that the focus on nicotine and its association with the negative health effects of cigarettes has overshadowed the arguably more widespread and accepted addiction to caffeine. Nicotine, when divorced from the harmful chemicals in cigarettes, is not the demonized substance it's often made out to be.

Drawing inspiration from the wisdom of the Buddha, who advocated for avoiding extremes and practicing moderation, I believe in a balanced perspective on nicotine use. While acknowledging the potential risks associated with excessive consumption, I advocate for the responsible use of nicotine, particularly in the form of NRT, even for recreational purposes.

In my conversations with patients, I often quote from the book “The Happiness Myth” to convey a simple yet impactful message about substance use:

“As far as what you should eat or how you should move around: everyone knows what feels healthy for them. You eat a meal with a gross amount of butter in it, you feel laden and greasy; you drink a lot, you feel poisoned; you miss sleep, you feel awful; you never move around much, it hurts to walk to the kitchen. For most people, the only really valid advice is the advice you would have assessed with your own eyes and ears, in any century, things like eat less, walk around more, get more sleep, and take pleasant poisons in moderation.

This perspective underscores the idea that, in moderation, the use of substances like nicotine can indeed be a positive experience. For those attempting to quit smoking or vaping, I emphasize the potential benefits of using NRT for as long as necessary, viewing it as a tool to support a healthier lifestyle free of the harmful toxins and longterm negative health symptoms that come with smoking and vaping.

While advocating for the responsible use of nicotine, it's essential to recognize that moderation is key. Extremes, whether in abstinence or excessive consumption, can lead to undesirable outcomes. As a physician, my primary concern is the well-being and health of my patients, and I believe that a balanced approach to nicotine use aligns with these goals.

In conclusion, nicotine, when divorced from the harmful elements in cigarettes, can be approached with a more nuanced perspective. NRT serves as a safe alternative to vaping and smoking, offering potential performance enhancements without the risks associated with other pharmaceutical enhancements. When used in moderation, performance enhancements from nicotine include improved cognitive function, enhanced reaction time, increased alertness, stress reduction, and mood enhancement.

Embracing moderation and steering away from extremes, I encourage patients to view nicotine as a tool for positive change, supporting them in their journey to quit smoking or vaping.

See this study for more on nicotine and pilot performance.


Dr. Larry Kaskel is a board-certified internal medicine physician. He currently owns a concierge medicine practice. In addition to caring for patients, he has been an instructor at the Feinberg School of Medicine.