It is estimated that there are 1 billion tobacco smokers in the world, and 80 percent of them live in low and middle income countries. In Nepal, according to STEPS Survey Nepal 2013, the prevalence of daily smoking was 15.8 percent. The use of smokeless tobacco in the form of oral snuff (khaini), chewing tobacco and gutkha was also found to be very common. The combined prevalence of tobacco use, smoke and smokeless, was recorded at 30.8 percent. Despite these figures, tobacco cessation programmes have still not been made a priority health intervention in Nepal.

Tobacco use in any form is the leading cause of preventable death worldwide. This is evident from the fact that life expectancy for smokers is at least 10 years shorter than that for non-smokers. Tobacco smoke contains about 7,000 chemicals, out of which 70 (like formaldehyde, hexamine, toluene and tar) are proven to cause cancer. Nicotine is the addictive component of tobacco products, but it does not cause cancer or other major illnesses related with tobacco use. It increases the level of dopamine in the brain producing a feeling of relaxation, increased alertness, pleasure and relief from stress. This reinforcing effect of nicotine makes it extremely addictive, more than even cocaine and alcohol. 

Smoking can damage every part of the body. The major impacts are on the cardiovascular system (stroke, hypertension, peripheral arterial disease), respiratory system (tuberculosis, pneumonia, chronic obstructive pulmonary disease) and reproductive system (reduced fertility, pregnancy related complications). Smoking has been known to cause diabetes, osteoporosis, cataract and gastric ulcer. Also, about 33 percent of all cancer diagnoses are attributed to tobacco use.

Most people using tobacco products don’t realise they have become dependent until they experience withdrawal symptoms when they stop consuming them. The Centres for Disease Control and Prevention reports that about 70 percent of smokers want to quit, and 55 percent of all smokers had tried to quit in the past year. Only about 3-7 percent of all smokers are able to quit annually, hence tobacco use disorder should be considered as a chronic relapsing disorder which may require up to 10 attempts (average five to six attempts) to be able to give it up completely. Smokers who want to quit always look for help; but for a long-term smoker, it is difficult to stop. There should be easy access to treatment for those who want to quit or even for those who are ambivalent about quitting. 

A solution from many quarters

There is not enough awareness that it is possible to quit smoking by seeking professional help. There is still an annoying social approval of smoking along with lack of awareness about the harm that tobacco products can cause. Hence, managing tobacco use needs a multi-sectoral approach with awareness programmes, cogent anti-smoking policies, public health interventions, and an evidence-based approach for individualised tobacco treatment.

Public health intervention includes age restrictions on purchasing tobacco and tobacco related products, substantial increases in tobacco taxation, banning smoking in public places, restricting sales to specific vending shops and antismoking advertisements. There has been substantial progress in Nepal in most of these areas, but the lack of inter-sectoral collaboration and consistent monitoring by the government is a barrier to its effective implementation. 

Individual tobacco treatment programmes are only beginning to become available in Nepal. Non-medication based treatment focuses more on behavioural interventions, smoking cessation groups and smoking cessation hotlines. Some of the strategies have a predetermined quit date which is achieved by gradually decreasing the amount of tobacco consumed, decreasing accessibility to tobacco products, not smoking in certain places like inside the house, around children, while travelling or in public places. Other evidence-based non-medical treatment includes supportive counselling, motivational interviewing, cognitive behaviour therapy, acceptance and commitment therapy and mindfulness-based interventions. These psychological interventions are highly structured and require professional expertise for a good outcome. 

When all else fails, medicine is key

Medication-based tobacco cessation regimens have consistently proven to be an effective way to stop smoking. Nicotine replacement therapy includes nicotine gums, lozenges, sprays, chewing gums and patches. Used in any form, it doubles the chances of abstinence from tobacco use. The trend of using electronic nicotine delivery systems, commonly known as e-cigarettes, has been spreading due to a misconception that they are less harmful. There is lack of consistent evidence to show that they help to give up smoking, and experts fear that they may actually re-normalise smoking and increase dual use of e-cigarettes and regular cigarettes. 

Medications used for nicotine substitution are medically approved and they reduce nicotine craving over time and increase chances of quitting successfully. Some of the medications like bupropion are readily available in Nepal while others such as varenicline are not as easily available. Medically supervised dosing of these medications combined with behavioural intervention increases chances of quitting severalfold. The duration of intervention differs from patient to patient, but it usually lasts around six to nine months. It is also important for tobacco users and their families to realise that there are several treatment modalities, and one should always collaborate with their treatment provider to select the best treatment option for them.

For most people, quitting can be as easy as a simple advice to stop smoking may lead to their giving it up, but preventing a relapse is the main challenge. Most relapses occur soon after a person quits smoking, yet some people relapse months or even years after the quit date. Avoiding triggers, staying focused, maintaining compliance with any form of intervention and developing new hobbies and interests are important to distract oneself from tobacco cues. Due to the chronic nature of tobacco use disorder, every successful quitter should always refrain from that one puff or snuff to maintain recovery. 

Dr Pant is a consultant psychiatrist at the Department of Psychiatry and Mental Health, TU Teaching Hospital, and Dr Pandit is an addiction psychiatrist working in Virginia, US