Tobacco use remains a severe health problem in India. Dr Niti Sapru, psychiatrist at Holy Family Hospital, Mumbai, on why stopping use of tobacco should be a two-pronged approach.
Tobacco use still a huge concern: India is the second highest consumer and producer of tobacco in the world. The recent Global Adult Tobacco Survey (GATS) reported 42.4 per cent of men and 14.2 per cent of women as current users of tobacco in all forms (smoke and smokeless)-in all 28.6 per cent of the population. Addiction or dependence on a substance of abuse-in this case tobacco-is considered a brain disorder involving circuits of reward, self-control and stress. Quitting is a revolving-door phenomenon with multiple attempts at leaving, seeking help and relapsing. Later age of first use, first intake of the day after an hour of waking, recent attempt to quit and healthcare provider's recommendation to quit are some of the positive factors in quitting tobacco use. Nicotine is the main chemical producing dependence when tobacco is used, reinforcing the individual to addictive behaviour. Any attempt at ending tobacco use needs to be multi-pronged.
Combine Nicotine Replacement Therapy with other therapies: Nicotine Replacement Therapy (NRT), combined with supportive counselling, is the most widely used treatment method in stopping tobacco dependence. The evidence that NRT (at times with Bupropion) helps quit smoking is now well accepted, and many clinical guidelines recommend NRT as a first-line treatment for people seeking pharmacological help to stop smoking. The Indian government too has included NRTs in the list of essential drugs-a major shot in the arm for the tobacco cessation therapy.
NRT aims to reduce motivation to consume tobacco and the physiological and psychomotor withdrawal symptoms through delivery of nicotine. NRTs contain lower amounts of nicotine without the harmful tar and carcinogens found in tobacco. There are various NRTs. Nicotine gum (Nicotex, Nicorette, Nicotine Polacrilex) releases nicotine on slow chewing and is available in strengths of 2 or 4mg, to be taken not more than 24 pieces of 2mg/day. The total duration of treatment advised is up to three months. Nicotine patches can be worn on the skin 16 to 24 hrs a day (three strengths: 7, 14 and 21mg), depending on number of cigarettes smoked per day and body weight. Nicotine lozenges are dissolvable tablets containing nicotine. Nicotine inhalers and nasal sprays are the other NRTs. Combining more than one NRT has yielded better results. The release of nicotine from smoking is immediate as against the slow release through NRTs. Patients must be counselled to have patience in dealing with this delay.
Non-Nicotine Replacement Pharmacotherapy: These address the impulse and withdrawal issues related to giving up tobacco. One of the approved medications is Bupropion-initiate at 150mg and increase to 300mg per day. The odds of quitting increase when Bupropion is combined with an NRT. The second is Varenicline-0.5mg to begin with, increasing to a maximum of 2mg per day. Some drugs like Nortriptyline and Clonidine are used at times, not as first-line therapies though. The duration for most of these therapies is 12 weeks.
Addiction being a multi-factorial issue, other therapies like motivational interviewing, the 5 As (Ask, Advise, Assess, Assist and Arrange) and 5 Rs (Relevance, Risk, Rewards, Repetitions and Roadblocks) also are successful as a counselling approach. Comorbid psychiatric conditions have to be assessed. A history of suicide attempts, psychoses and seizures may obviate use of some of these therapies.
The risk of relapse is the highest around six months post quitting and only 4 per cent of those who have quit for more than two years go back to tobacco use. Our endeavour should be to reach that golden number of two using all available means at our disposal.