"I am going to be a dad in three months. I want to quit smoking before we bring our baby home," said a soon-to-be father, as he walked into Dr Samir Parikh’s Fortis Tobacco Cessation Clinic in Gurgaon this week. The 29-year-old, who did not wish to be named, wanted a quick fix to kick the butt. Elsewhere, Shweta Rajshekhar, a 36-year-old consultant, has a different reason for quitting.
"If you’re a smoker, the odds are stacked against your getting an opportunity to smoke. In most countries, almost all public places — offices, restaurants, cabs, malls, bars, you name it — are smoke-free," says Rajshekhar, a frequent flyer to the US’s Silicon Valley. "After 15 years of smoking, I am now tired of hunting for places to smoke. So I have decided to quit."
Growing restrictions and the many diseases (29, at the World Health Organisation’s last count) such as cancers, heart diseases, stroke and lung diseases, that are associated with tobacco use, are prompting many like Rajshekhar to consider quitting.
Rewiring the brain
Quitting tobacco use, however, is far from easy. A cigarette is a highly efficient nicotine delivery system that induces pleasure, reduces stress and anxiety, and causes addiction to tobacco smoking. People who start smoking young find it harder to quit smoking later on in their lives because early nicotine exposure alters the ‘hard-wiring’ of the brain that occurs during adolescence and young adulthood.
US President Barack Obama, for one, has admitted to struggling with nicotine dependency because he started smoking young. The US President’s third ‘periodic physical exam’ report released in June 2014 records his "occasional use" of nicotine gum, which since then he has been caught chewing on camera during meetings with other heads of state, including while he watched India’s Republic Day Parade earlier this week.
Nicotine sustains tobacco addiction by acting on nicotinic cholinergic receptors in the brain to trigger the release of neurotransmitters such as dopamine, which promotes pleasure, and GABA (gammaaminobutyric acid), which is the brain’s natural Valium and has relaxation, antianxiety and anti-convulsive effects.
Get a grip
According to a review article in The New England Journal of Medicine, the basis of nicotine addiction rests on its effects on the brain, but addiction is also influenced by genetics and social conditions. This holds true for all tobacco products, including bidis, hookahs, snuff, gutkha and other forms of chewing tobacco.
"Like all addictions, tobacco addiction involves the interplay of pharmacology (improve mood, both directly or through relief from withdrawal symptoms), genetics and social conditioning, which includes peer pressure and marketing, so quit-tobacco programmes have to be designed accordingly," says Dr Samir Parikh, head of mental health and behavioural sciences at Fortis Hospitals.
"Cessation programmes have to be individualised. Quitting cold turkey works for some, while others need to reduce consumption over time," says Dr Sameer Malhotra, head of psychiatry at Max Hospitals.
What works well though is a combination of counselling and medication, depending on the person’s motivation and for how long has he or she been using tobacco. "The higher the motivation, the easier it is to quit," says Dr Malhotra. "About 30% people at my clinic are walk-ins who have decided to quit on their own, while others are referrals who have been asked to stop because they have developed health problems, such as heart or lung disease."
Relapse is common among tobacco users. Data from the US National Institute on Drug Abuse shows that three in four former smokers end up relapsing within six months of quitting.
"When all else fails, a combination of counselling and stress management strategies along with prescriptive crutches such as nicotine gum and anti-anxiety medicines usually do the trick," says Dr Parikh.