Breaking Free!

Every year, on May 31st, the world unites to observe ‘World No Tobacco Day’, an initiative led by the World Health Organization (WHO) to highlight the devastating health impacts of tobacco use and advocate for policies to reduce its prevalence. Tobacco consumption is one of the leading causes of preventable diseases and deaths globally, affecting millions and burdening healthcare systems worldwide.

Thanks to the efforts of various health organisations, NGOs and government bodies, today, people are more aware of the wide-ranging health impacts of tobacco use and smoking, such as cancer, heart disease, COPD and emphysema. However, there are also lesser-known but equally grave consequences that affect mental health, skin, and overall well-being. Many individuals also grapple with the challenges of quitting tobacco, facing not only the physical addiction but also the psychological struggles that accompany it.

Apart from the health burden, tobacco usage also induces a huge financial burden on individuals and society. The economic cost of smoking is enormous, including direct medical costs and lost productivity. According to the report "Economic Burden of Tobacco Related Diseases in India" published by the Ministry of Health and Family Welfare (MoHFW), the total economic costs attributed to tobacco use from all diseases in 2017-2018 for persons aged 35-69 was a whooping USD 27.5 billion.

Why is tobacco bad for health?

Tobacco is consumed in various forms worldwide. The most common method is smoking, which includes cigarettes, cigars, bidis, pipes, hookahs, and cigarillos. Smokeless tobacco forms are also common - such as chewing tobacco, snuff, gutka, khaini, snus etc. Additionally, electronic nicotine delivery systems (ENDS), including e-cigarettes, vape pens, mods, and pod systems, have gained popularity in recent years as alternatives to traditional smoking.

Cultural and regional variations prevail in tobacco use indicating diverse patterns of use and addiction across geographies. Despite these differences in consumption methods, all forms of tobacco use are associated with severe health risks, including cancers, respiratory diseases, cardiovascular diseases, and oral health issues.

Tobacco contains a myriad of toxic substances and chemicals that significantly contribute to its harmful effects on health. Notably, it includes nicotine, which is the primary addictive component in tobacco, leading to dependence and making it difficult for users to quit. It affects the nervous system, increases heart rate and constricts the blood vessels (vasoconstrictor). As the blood vessel constricts and reduces its diameter, the pressure of the blood inside increases leading to hypertension-associated complications. Cigarette smoke also contains ammonia, which enhances the absorption of nicotine thereby worsening its addiction.?

Further, the tar from smoking contains numerous carcinogens which can accumulate in the lungs and cause lung cancer. Apart from nicotine and ammonia, cigarette smoke also contains formaldehyde and acrolein which are well-known carcinogens and respiratory irritants further increasing the chances of cancer. Yet another toxic by-product of tobacco smoke is carbon monoxide, a gas that reduces the blood's oxygen-carrying capacity and increases the risk of cardiovascular diseases. Tobacco smoke also contains benzene, a Group 1 carcinogen as per the International Agency for Research on Cancer (IARC) that can cause severe oxidative stress and damage the bone marrow, leading to a decrease in red blood cells (anemia), white blood cells (leukopenia), and platelets (thrombocytopenia).?

The list of cancer-causing components in tobacco goes on - hydrogen cyanide, nitrosamines, polycyclic aromatic hydrocarbons (PAHs), toluene, acetaldehyde, and heavy metals such as cadmium, lead, and arsenic are all highly dangerous to various organs including lung, heart, kidney, bones, and the nervous system.

Tobacco use (both smoking and chewing) also poses significant risks to oral health. Apart from oral cancer, it can cause inflammation of the gums (periodontitis), tooth decay, oral lesions, altered sense of taste and smell and reduced ability to enjoy food and detect odours.

Are e-cigarettes (vaping) a less risky option?

E-cigarettes heat a liquid (commonly known as e-liquid or vape juice) that typically contains nicotine, flavourings, and other chemicals. This heating process creates an aerosol, that looks similar to vapour, which the user inhales. This process of? ‘vaping’ may be a better alternative than smoking traditional cigarettes for current smokers who are unable to quit. This is because vaping has comparatively fewer toxic chemicals and carcinogens as compared to smoking cigarettes.

However, vaping is not devoid of health risks and is not suggested - especially for non-smokers and young adults. Vaping still involves inhaling nicotine which is highly addictive and poses significant risks to the cardiovascular system.

Steps to Successfully Quit Tobacco

There is no single right way to quit tobacco. However, here are some steps that one can follow to achieve that goal. Whether trying to quit smoking or chewing tobacco, the first step is to decide to quit. This decision must come from a personal commitment; reflect on the reasons for quitting, such as concerns about health, financial savings, and improved quality of life. Write down these reasons in a book or a diary; it will be a powerful reminder and motivation throughout the quitting process.

The next step is to set a specific ‘Quit-Day’. Do not choose a day within the next 3 or 4 days, as the chances of failure are very high - especially if you have been a smoker for several years. This is important, to managing the withdrawal symptoms that can be psychologically very daunting. At the same time do not choose a quit-date more than a month away to ensure you remain committed, without procrastinating.

Mark this date on your calendar (possibly with a red ink pen) and inform some of your close friends, family, and colleagues about your plan. Start by removing all tobacco products from your environment and stocking up on substitutes like sugarless gum, carrot sticks, pickled radish etc. Seeking professional help also can enhance your chances of success.

Practice delaying the urge to use tobacco and thus cut down on the number of cigarettes or the amount of smokeless tobacco used daily. Identify the triggers that prompt cravings and find coping mechanisms. For example, the urge to smoke immediately after a meal is a very common trigger for many. Chewing gum immediately after meals to change the taste in the mouth or taking a short walk can distract from that urge.

Being around friends or colleagues who smoke can be yet another trigger. Inform them about your decision to quit and request their whole-hearted support. Choose smoke-free environments or no-smoking zones for socialising or when taking a quick break from work.

As you reach the quit day, refrain from using tobacco entirely and keep busy with activities that distract from cravings. Stay hydrated, avoid alcohol, and change your routine to break the association with tobacco use. Practice deep breathing, drinking water, and engaging in different activities to overcome strong urges. A comprehensive approach, combining planning, support, and behaviour modification, can greatly increase the likelihood of successfully quitting tobacco.

Avoiding Rationalisation

To overcome urges or cravings, it is important to recognise and acknowledge rationalisations as they arise. Rationalisations are deceptive thoughts that may seem plausible at the moment but are not grounded in reality. Entertaining such thoughts, even briefly, can serve as a justification for using tobacco.

This is the last one I will smoke

"I will quit tomorrow"

"Air pollution is more harmful than smoking"

"My uncle used to smoke all his life and he lived past 90"

"I need tobacco to wade through this rough patch"

are some examples of rationalising thoughts. Rationalisations can be dangerous and can fail you in your No-Tobacco journey. It is helpful to document these rationalisations as they surface and acknowledge them for what they are - i.e tempting thoughts that lead one back to smoking or chewing tobacco.

Managing Tobacco Withdrawal

Withdrawal from tobacco occurs when the body, having become dependent on nicotine, experiences a range of physical and psychological symptoms upon stopping its use. This dependency develops due to nicotine's actions on the brain's reward pathways (mesolimbic pathway) associated with pleasure and reinforcement.

When we consume tobacco, nicotine binds to nicotinic acetylcholine receptors, triggering the release of neurotransmitters like dopamine, which creates feelings of pleasure and reinforces tobacco use behaviour. Over time, the brain adapts to this regular nicotine intake by reducing the number or sensitivity of receptors, requiring more nicotine to achieve the same effects.

When tobacco use is stopped suddenly, nicotine levels plummet, leaving these receptors unoccupied and resulting in withdrawal symptoms as the body seeks to restore balance. Common withdrawal symptoms include intense nicotine cravings, irritability, mood swings, difficulty concentrating, increased appetite, sleep disturbances, physical discomfort, anxiety and even depression. These symptoms arise due to the neurotransmitter imbalances caused by the sudden absence of nicotine.

As dopamine levels decrease, individuals may experience heightened feelings of irritability and depression along with impaired cognitive functions, sleep patterns, and appetite regulation.

Reducing and managing withdrawal from tobacco involves a combination of strategies to address both the physical and psychological aspects of dependence.        

Using Nicotine Replacement Therapy (NRT) products such as nicotine patches, gum, lozenges, nasal sprays, or inhalers can help reduce withdrawal symptoms by providing a controlled dose of nicotine. The dosage of NRT must be tapered down gradually to facilitate the weaning process and reduce dependence. Certain medications, such as bupropion and varenicline, can help reduce cravings and withdrawal symptoms by affecting brain chemistry. However, these medications should be used only under the guidance of a medical doctor. Your doctor may prescribe these medicines only if there is a severe nicotine dependence.

Seeking support through counselling can provide valuable emotional support, coping strategies, and encouragement throughout the quitting process. Behavioural therapies can help individuals identify triggers, develop coping skills, and reinforce positive behaviours to maintain tobacco abstinence.?

Adopting a healthy lifestyle with regular physical activity, a balanced diet, adequate hydration, and sufficient sleep can help manage withdrawal symptoms apart from improving overall well-being.

As the world observes World No Tobacco Day, let us reflect on the impact of tobacco use on individual health and well-being. From the devastating health consequences to the significant economic burden it imposes, tobacco use remains a formidable challenge requiring multifaceted solutions. Despite widespread awareness of its harmful effects, tobacco consumption continues to take a heavy toll on individuals and societies alike. By empowering individuals with the knowledge, resources, and support needed to overcome tobacco addiction, we can create healthier communities and alleviate the burden of tobacco-related diseases.