HOW TO KICK THE BUTT
New research and cessation techniques as well as a committed cessation cadre promise to help wean smokers off the habit more permanently, and in the bargain reduce the burden of tobacco-related disease in the country
How do you resist it? That wetting of filter, the smell of unlit tobacco awakening your senses, the feeling of warmth washing over your body, soothing the frayed nerve and dissipating all accumulated tightness. Cigarettes can be a constant companion, your friend through pleasure and pain, a coping mechanism when you are feeling stressed or angry. For Prerna Barde, a 29-year-old marketing executive from Mumbai, “A cigarette is like my second skin. My happiness is linked to it. I find it difficult to do anything without one.” Trouble is, the more nicotine lures you in, the more difficult it becomes to shake it off or escape the havoc it will wreak on your lung or mouth. It is something people know. Every so often, they try to break off the relationship too. But very few manage to make the break permanent. India, in fact, has one of the lowest rates of smoking cessation in the world. According to the World Health Organization’s 2019 Global Adult Tobacco Survey (GATS), 55 per cent of smokers in India want to quit, but have been unable to do so. Only about 4 per cent actually succeed, according to the WHO.
New research now offers hope to those who want to quit smoking but have failed. For decades, the most common answer to tobacco cessation was to put a hard stop or opt for nicotine-replacement therapy (NRT) in the form of gums, patches or sprays. If it led to emotional and physical withdrawal effects, there was medicine for that too. Today, the entire approach to cessation has changed. An October 2021 study on tobacco cessation by the University of Bristol published in the American journal Addiction recommended a combination approach using behavioural counselling, NRT and new modern drugs such as varenicline and bupropion. These drugs, in fact, have come into modern medical use only early this year, with the WHO characterising them as safe and effective for tobacco abstinence. The new medicines suppress the craving for nicotine without having to depend on any substitute and help manage withdrawal symptoms.
“In my experience, simply asking someone to quit cold turkey and giving NRT drugs hardly ever works,” says Dr Prashant Chhajed, director of pulmonology at the Fortis Hiranandani Hospital in Vashi, Mumbai. “We need awareness, motivation, a thorough understanding of triggers, a psychology assessment, building social support and then quitting and medicine.”
One reason why smokers find it difficult to give up smoking for good is their inability to control triggers and going into a relapse. For Nikhil Gupta, a 32-year-old MBA student in Noida, it was a late-night office party sometime in June. It had been four months since he had picked up a cigarette. On that particular day, he succumbed. He has been smoking almost half a pack daily since, reverting to a habit he thought he had gotten rid of. “This is the third time I have had a relapse,” he says. “I don’t know if I have the strength to stop again.”
Since self-regulation is such an elusive beast, doctors now recommend that smokers seek professional support. “Cessation support can help addicts identify, understand and cope with triggers that cause a relapse,” says Dr Vikrant Mohanty, head of the newly-inaugurated National Resource Centre for Oral Health and Tobacco Cessation at the Maulana Azad Institute of Dental Sciences (MAIDS) in Delhi, who has two decades of experience in the field. The government has mandated that a tobacco cessation clinic be set up in all government dental colleges in India. Dentists have been roped in for the exercise as India has over 281,000 registered practitioners and 315 dental colleges with 35,000 faculty members and 26,000 students each. Also, as Dr Mohanty points out, “A dentist can just peer into a mouth and know right away if someone is using tobacco, and since they meet patients multiple times, support and motivation to quit can be given over a long period.”
NEW WAYS TO QUIT AN OLD HABIT
“Most people who try to quit,” says Mumbai-based psychiatrist Dr Kedar Tilwe, “do so without understanding the addiction part of tobacco and are thus not prepared for how the body and mind will respond.” It is a well-established fact that nicotine, a chemical found in tobacco, has a powerful and direct impact on dopamine release in the brain. Over time, the brain starts to seek tobacco as a means for continued stimulation. “Many,” says Dr Tilwe, “start smoking to curb anxiety. But in the gaps that they are without tobacco, they start to have even more anxiety, triggering a clear dependency pattern.” Unable to sustain the attempt to wean away from smoking, they restart after a few weeks or months, sometimes even years.
It is becoming increasingly clear that the mere desire to quit may not be enough, those who truly want to stop
“Cessation support can help addicts identify, understand and cope with the triggers that cause a relapse” — DR VIKRANT MOHANTY
Head, National Resource Centre for Oral Health and Tobacco Cessation, Maulana Azad Institute of Dental Sciences, Delhi
smoking need assistance. “A lot more people want to stop using tobacco today,” says Dr Ashish Kumar Prakash, respiratory medicine specialist at Medanta - The Medicity in Gurugram, “but this can only be possible if we provide them accessible and affordable assistance.” One reason why most smokers avoid counsellors is because they think they have nothing new to offer. However, professionals are now devising personalised solutions to help individuals abstain from tobacco use.
“You don’t start with quitting,” says Dr Chhajed, “but prepare to quit first.” To do so, counsellors recommend the 5Rs of cessation—the relevance of quitting, the risks of using tobacco, the rewards of quitting, the roadblocks on the journey to quit, repeated consultations with cessation experts and the fact that repeated attempts may be needed before one succeeds. “I have had patients who
had tried quitting 8-10 times before succeeding. The key was to keep them going through counselling that was tailored exclusively for their situation and personality,” says Dr Tilwe.
Behaviour therapy has become crucial in the cessation arsenal. “We motivate people, help them identify triggers and find solutions for them through behaviour therapy,” says Dr Nimesh Desai, director of the Institute of Human Behaviour and Allied Sciences in New Delhi. But behaviour therapy itself has changed. “It is a lot more detailed and personalised today,” says Dr Mohanty. For example, instead of just asking people to find their triggers for smoking, counsellors ask patients to write down why they smoke, when they smoke and the trigger that makes them reach for a cigarette, and to avoid all such situations going forward.
The most commonly suggested non-medical advice to stop smoking at one time was to chew ice or gum, drink water, or hold a pen in the hand, says Dr Mohanty. Today, cessation research has thrown up a whole gamut of other alternatives—cleaning the house, meditation, going for a run, calling friends or a counsellor, or simply noting down the benefits of quitting in a journal. There is no longer a one-size-fits-all approach to cessation, solutions are customised as per the person and situation. “You pick the distraction or coping mechanism that works for you,” says Dr Tilwe. Indeed, a new study looking at 2,500 smokers, and published last month in the New England Journal of Medicine, showed that those who had a financial reward to quit had a higher success rate in forsaking tobacco use. Doctors have also observed how in the past few years asking smokers to reward themselves with a holiday, new product or an expensive meal for every month they go without smoking has improved motivation levels.
Post-Covid, a 2022 study by the non-profit Foundation for a Smoke Free World (FSFW) also found that many tobacco users in India turned to newer coping mechanisms such as exercise, yoga and meditation. Many doctors also advise their patients to stay away from social events or find new strategies to cope with stress situations other than turning to tobacco. “One has to delink a person’s mind from tobacco, they have to stop seeking it for happiness, temporary relief, peace, or whatever positive emotions they link with it. At the same time, cessation also has to keep a person motivated enough because it is difficult to keep going. But keep going we must,” says Dr Tilwe. The allusion to ‘positive emotions’ touches on a difficult aspect of cessation, because of the way smoking is associated with seductive pop-cultural tropes, and the idea of ‘rebellion’ and non-conformism.
“Many start smoking to curb anxiety. But in the gaps that they are without tobacco, they start to have even more anxiety, triggering a clear dependency pattern” — DR KEDAR TILWE
Psychologist, Mumbai
TRAINING FOR CESSATION
However, while the research and strategy for cessation have advanced globally, a committee set up by the WHO, the Union ministry of health and family welfare and the Dental Council of India in 2018 found one significant lacuna in cessation support in India—training in modern methods. As per the FSFW, less than a third of the physicians in India receive training in cessation and a third of them are smokers themselves. Indeed, the government app—mTobaccoCessation—registered a quit rate of only seven per cent after six months of use in 2020 as it had only 12,000 formally listed trained personnel. This, despite two million registrations in the first month alone.
“We have now developed a training manual with 18 tobacco cessation experts,” says Dr Mohanty. From next month onwards, the national resource centre at MAIDS will run a training programme every four days for a 40-strong batch of dentists in every public dental college in every state. In the end, participants will be tested and awarded a certificate in tobacco cessation. Dental colleges, in turn, will conduct their own training programmes. “We are hoping for a ripple effect so that we have support providers across the nation trained in a modern and scientific understanding of tobacco use and cessation,” says Dr Mohanty.
Cessation became all the more important after India banned vaping and e-cigarettes in 2019. “I was doing fine,” says 28-year-old Pune student Arjun Seth (name changed), “till the ban on vape. Now I have relapsed.” Regular cigarettes deliver over 7,000 harmful chemicals besides nicotine. Lower nicotine content vapes or e-cigarettes had become the alternative for many as a means to slowly ease the dependence on higher nicotine cigarettes. But even as NRT remains part of the overall cessation strategy, doctors advise its use only for 1-3 months so that the replacement products themselves do not become a source of addiction. “Medicine and nicotine replacement should be taken under supervision and in a planned manner. These must be supplemented with lifestyle changes,” says
Dr Chhajed.
WHY CESSATION REMAINS CRUCIAL
Nearly 267 million adults (15 years and above) in India use tobacco, according to GATS India findings in 2016-17. Worse, the age at which people start using tobacco is still worryingly low. The fourth round of the Global Youth Tobacco Survey conducted in 2019 by the International
Institute for Population Sciences (IIPS) under MoHFW in 987 schools found that one-fifth of the students aged 13-15 had used tobacco. And that 38 per cent of cigarette, 47 per cent of bidi smokers and 52 per cent of smokeless tobacco users initiated the use before their 10th birthday.
If tobacco addiction starts early, so does the appearance of ill effects. “More and more young people are coming in with lung cancer, heart attacks and bronchitis,” says Dr Vivek Anand Padegal, director of pulmonology at Fortis Hospital, Bannerghatta Road, Bengaluru. “Most of them can be connected to the fact that they have been using tobacco for years.” According to the WHO, seven per cent of all deaths in India, or around 1.2 million per year, can be attributed to tobacco use. We lose $27.5 billion (Rs 2,197 lakh crore) annually to diseases related to tobacco use. The most common and concerning of these diseases is cancer, with smoke from tobacco now known to cause over 27 per cent of all cancers and 90 per cent of all oral cancers in India. As Dr Shishir Shetty, a medical oncologist at Apollo Hospitals, Navi Mumbai, explains, “Deeper lung smoke over the years can cause changes in cells.”
Yet people find it difficult to quit smoking even though they are aware of its consequences. The government for its part has intensified its efforts to discourage smoking and tobacco use. As part of the National Tobacco Control Programme, all tobacco companies are required to use 85 per cent of the space on cigarette packs for pictorial health warnings. Tobacco also falls in the highest 28 per cent slab of GST.
The Covid-19 pandemic was another reason for people to quit smoking as part of an overall desire to improve their quality of life. The FSFW study found that two out of three smokers in India attempted to quit smoking due to health reasons during the lockdown. The WHO predicts that tobacco use in India will fall by 30 per cent by 2025. The MoHFW claims there has already been a reduction of about 8.1 million smokers in the past decade.
But for every person who wants to quit, there is another who falls back into the habit. “This addiction affects their relationship, productivity, self-esteem and physical well-being,” says Dr Viswesvaran Balasubramanian, interventional pulmonologist at Yashoda Hospitals in Hyderabad. “The only way they can get out is through trained and quality support.” Dr Mohanty agrees. “If we are to bring down the burden of tobaccoinduced diseases, we must focus on this huge group that has the willingness but not the means to quit.” It’s an SOS—and a lifeline—for smokers. ■
“A lot more people want to stop using tobacco today, but this can only be possible if we provide them affordable and accessible assistance” — DR ASHISH KUMAR PRAKASH
Specialist, Respiratory Medicine, Medanta — The Medicity