Breaking the cycle of addiction: Innovative approaches to tobacco cessation

The tobacco epidemic is one of the biggest health crisis that the world is facing today and according to WHO (World Health Organization) in 2020, 22.3% of the global population used tobacco, 36.7% men and 7.8% women but tobacco kills more than 8 million people each year through direct intake and second hand smoke while tobacco use disorder has significant economic and health care costs hence, de-addiction from tobacco is the need of the hour.

In India, tobacco-related cancers (TRCs) contribute nearly half of the total cancers in males and one-fifth in females while globally, 32% of total cancers were attributable to TRCs in males while in female this percentage was 15%

India is the second largest producer and consumer of tobacco products in the world and as per the Global Adult Tobacco Survey 2017, 42.4 % Indian men and 14.2% females accounting for 28.6% of population (266.8 million) use tobacco in smoked and or smokeless forms in our country but despite the fact that smokers and tobacco users attempt to quit (about a third try), the percentage remains low with 16.8% smokers and 5.85% smokeless users and much needs to be done on priority to tackle the growing tobacco-associated disease incidence including cancer.

In an interview with HT Lifestyle, Dr Aparna Ramakrishnan, Consultant – Psychiatry at Kokilaben Dhirubhai Ambani Hospital in Mumbai, shared, “US FDA approved medications for tobacco cessation include VARENICLINE and BUPROPION which decrease tobacco craving and withdrawal symptoms and reduce the reinforcing efficacy of nicotine.” She suggested:

NICOTINE REPLACEMENT THERAPIES (NRT) including NRT patches, gums, lozenges, inhalers and nasal sprays can be used for treatment of Nicotine dependence.

NRTs lead to decreased absorption, slower and steadier delivery of nicotine, thus preventing reinforcement of addiction. Research shows that combination NRT- long-acting patch and one of the short-acting NRTs gum, lozenge, nasal spray, or inhaler are more effective.

Non FDA approved medications which have shown efficacy in smoking cessation include CLONIDINE, NORTRYPTILINE, CYSTISINE (a naturally occurring plant alkaloid). Research is currently ongoing for newer medications and nicotine vaccines as tobacco cessation strategies.

E-Cigarettes and VLNC (Very low nicotine content) cigarettes are some harm minimization strategies.

2. PSYCHOSOCIAL APPROACHES – American Psychiatric Association has recommended a simple, practical strategy for clinicians for tobacco cessation treatment. THE FIVE A model which can be applicable in Indian scenario too.

ASK: about tobacco use

ADVISE: to quit tobacco in a personal, non judgemental manner

ASSESS: for motivation to quit. Build rapport, Use Motivational interviewing techniques to build motivation to quit.

ASSIST: those ready to quit. Provide goals- setting a quit date, developing a quit plan, considering cessation medications, identifying triggers, building, maintaining and buffering social support and using community resources

ARRANGE: for follow up

Establishment of smoke free buildings, increased taxation on nicotine products, warning signs displayed prominently about the health hazards of tobacco use, preventing advertisement of these products in media are also techniques used for deterring tobacco consumption

Psychological intervention techniques like BEHAVIOUR THERAPY, ACCEPTANCE AND COMMITMENT THERAPY (ACT), Motivational Enhancement Therapy (MET) and Contingency management (pairing positive reinforcement to desired behaviour or outcome) are some techniques which have been found to be effective in tobacco cessation

3. Innovative techniques include setting up of QUITLINES where individuals can call a specific helpline and speak with counsellors, mental health professionals who address behavioural, cognitive, affective and health education domains of quitting. There are also several Digital platforms like Quit smoking websites (eg Smokefree.gov.) which contain information, educational modules, crisis intervention strategies and support throughout the journey of deaddiction. They cater to specific population like women, teens etc, have text services and smartphone apps too. Smartphone apps like QuitGuide, MyQuit, SmartQuit, and Craving to Quit are other creative strategies in the realm of tobacco cessation. Digital gaming is another ingenious strategy for quitting tobacco. Video games for quitting smoking include Nicot, where users crush virtual cigarettes; Lit 2 Quit, which guides users through breathing exercises; and QuitIt, with users practicing strategies for coping with smoking urges and maintaining abstinence by going through episodic stories. Other social media platforms like Facebook, Twitter have ages dedicated to encouraging and assisting members who seek help for quitting tobacco.

Dr Anil D’Cruz , Director Oncology at Apollo Cancer Centers in Navi Mumbai, explained, “Addiction to tobacco is of two types: psychological and physical. The former can be tackled easily with counselling and behavioural modification and recent tobacco users and those who consume in small/ moderate amounts are the ones that fall into this group. Long term users have physical dependence and need both counselling and medication which includes replacement therapy to help them quit. Literature is replete with studies that all attempts to help people quit their habit must be continuous and sustained rather than just the occasional attempt. Today there are many innovative methods to help in those keen on quitting. We must remember that proper counselling where a person understands the harmful effects of tobacco consumption and the benefits of quitting form the backbone of any quit program.”

He asserted that there are a number of smart new digital health interventions for tobacco consumption that are more appealing among the youth and young adults. Some of these include:

•Smartphone Applications: There are a number of quit-smoking apps available that can provide real-time support and feedback, track progress, offer encouragement, and deliver evidence-based strategies for dealing with cravings. They can also link users with a community of people who are on the same journey, providing much-needed social support.

• Virtual Reality (VR) Therapy: VR can be used to simulate real-life situations that typically trigger tobacco cravings, such as social gatherings, stressful situations, or after a meal. Within the controlled environment of VR, individuals can be taught coping strategies to manage these cravings.

• Text Messaging Programs: These programs deliver supportive messages and tips to help individuals quit smoking. They can be personalized to the individual’s quit date and offer interactive features where individuals can text in during a craving or when they need immediate support.

• Artificial Intelligence (AI) and Machine Learning (ML): AI and ML can be used to predict an individual’s behavior patterns and high-risk situations for tobacco use. This information can then be used to provide personalised interventions, such as timely motivational messages, reminders or offering alternative coping strategies.

• Telemedicine: Virtual appointments with healthcare providers can give individuals access to professional medical advice and support for tobacco cessation, making it easier for those who might have difficulty making in-person visits due to location, work schedule, or ongoing pandemic conditions.

• Wearable Technology: Devices like smartwatches can monitor physiological changes that may indicate a craving and can deliver on-the-spot interventions such as stress reduction techniques or distractions.

Dr Anil D’Cruz added, “While digital health tools can provide significant support, successful tobacco cessation also requires a strong personal commitment and, in some cases, professional medical guidance.” Highlighting that there are a number of pharmacological interventions to aid Tobacco Cessation, he revealed:

• Nicotine Replacement Therapy (NRT) is one of the most common approaches. It provides controlled doses of nicotine to the body to alleviate withdrawal symptoms and reduce cravings. NRT is available in various forms such as patches, gum, lozenges, inhalers, and nasal sprays. These products are designed to gradually wean your body off nicotine.

• Bupropion is a non-nicotine medication originally used as an antidepressant. It helps reduce cravings and withdrawal symptoms by influencing chemicals in the brain associated with nicotine addiction. Bupropion is often used in combination with NRT for an effective cessation strategy.

• Varenicline is another non-nicotine medication that works by blocking nicotine receptors in the brain. This reduces the pleasurable effects of smoking and helps alleviate withdrawal symptoms.

• Nortriptyline, an older type of antidepressant, has also shown to be effective in helping people quit smoking when used at higher doses.

• Clonidine, originally developed to treat high blood pressure, can also aid in smoking cessation, although it’s not a first-line treatment due to its potential side effects.

Dr Anil D’Cruz said, “These medications can significantly increase your chances of quitting smoking, especially, when combined with behavioural interventions. However, they should be used under the supervision of a healthcare professional due to potential side effects and interactions with other medications. It’s important to discuss these methods with a healthcare professional to determine the most effective strategy for each individual’s situation.”

Bringing his expertise to the same, Dr Kunal Oswal, BDS, MPH, MHM -Screening and Early Detection at Karkinos Healthcare, said, “The escalating burden of tobacco-related health issues, especially among our adolescents, is a matter of great concern. Young adults today are at the frontline of the battle against tobacco addiction due to the alarming trend of the glamorization of smoking and smokeless tobacco. This not only normalizes tobacco use, but dangerously downplays the grave health implications tied to it. It’s crucial to understand that every puff of a cigarette and every pinch of smokeless tobacco that includes pan masala and chewing tobacco erodes the cornerstone of our health. There is immense myths among the users about its use as fashion, coolness, reduce anxiety and pain, improve concentration, wellbeing and much more. The solution lies in breaking the cycle of addiction, and this calls for innovative approaches tailored to the unique challenges faced by the younger generation. The key is to blend cutting-edge therapies and technological advancements with personalized interventions, creating a comprehensive strategy for tobacco cessation. It’s a timely call to protect our youth from the misleading advertisement, promotion of tobacco through different forums and prevent initiation as “Prevention Better than Cure”.”

He elaborated, “Evidence-based medical therapy, are available but of limited use from Indian context and hence needs proper dosing and education. The therapy mainly nicotine replacement therapy (NRT) and prescription medications like bupropion and varenicline, can effectively manage withdrawal symptoms and cravings. The pairing of these medical treatments with a holistic approach enhances the likelihood of successful quitting, minimizes relapse, and ensures sustained support for a Tobacco-free life. Remember, tobacco cessation is not merely about halting a habit. It’s about reclaiming your health, your freedom, and your future. We have the tools and the strategies; all we need is a commitment to the journey. Together, let’s extinguish the allure of tobacco, one steps at a time. Be a superstar in your life. Use STAR Approach for tobacco cessation i.e. S – Set a quit Date, T- Tell your family and friends, A- Anticipate Challenges, R – Remove all tobacco products near you.