Smoking Kills in Many Ways, Quit Smoking Now
Why become a victim of cancer and other ugly diseases, when life has so much to offer, says Dr Lancelot Pinto, consultant respirologist and smoking cessation therapy specialist at Mumbai's PD Hinduja Hospital.
How important is it to stop smoking?
One cannot emphasize enough the benefits of stopping to smoke, both in terms of the gain in quality of life, and the prevention of smoking-associated illnesses, which cover a very wide spectrum. What is encouraging, however, is that most individuals (across education levels, socioeconomic strata and geographical location) know that it is important to stop smoking.
What are the short- and long-term benefits of stopping smoking?
In as early as 24-48 hours after stopping to smoke, carbon monoxide levels in the blood (a molecule that is generated in response to cigarette smoke, and that binds more avidly to haemoglobin than oxygen, thereby reducing the oxygen-carrying capacity of the blood) start returning to normal. Blood pressure levels start dropping in a similar timeframe, and quality of life potentially starts improving, with an improved sense of taste and smell.
Within 2-4 weeks of stopping to smoke, heart attack and stroke risk levels begin to fall, lung function gradually begins to stabilize, and the cough and phlegm production associated with the irritation caused by cigarette smoke begins to get better.
Over the first year after stopping to smoke, the risk of heart attacks, strokes, and insulin resistance progressively improves, and is reduced to close to half of that of an individual who continues to smoke. Cilia, which are present on the surface of the lung tubes (bronchi), which beat in a wavelike manner and clear the lungs of irritant particles, are paralyzed and damaged by cigarette smoke. These become normal over the first year after stopping to smoke, and mechanisms to protect the lungs and prevent damage are restored.
Between 5-15 years after ceasing to smoke, an individual’s risk for most cardiovascular diseases and diabetes starts resembling that of an individual who has never smoked. Although the risk of smoking-associated cancers (such as lung, mouth, throat, esophagus, pancreas) still remains higher than those individuals who have never smoked, the risk gets lowered to less than half of what it would have been had the person continued to smoke.
One of the other significant benefits of stopping to smoke is the benefit to your loved ones. Children of individuals who smoke have a significantly higher risk of recurrent upper respiratory tract infections, and passive smoke exposure has been associated with numerous ailments. Stopping to smoke is as much an investment in the health of those one cares about as much as it is an investment in one’s own health.
You have started a successful intervention programme, the Smoking Cessation Therapy. Could you give us a little background on this therapy and how does it work?
Smoking cessation therapy helps individuals stop smoking comfortably. The key here is helping people do so comfortably, and without suffering. The philosophy stems from 3 tenets:
- Most individuals want to stop smoking and know that smoking is harmful
- Most individuals have tried to quit cold turkey, and have been unsuccessful (the success rates of stopping to smoke without any assistance is approximately 3% at one month after the stop date)
- The reason most individuals re-start smoking is because of the often disabling andunbearable withdrawal reactions to the lack of nicotine.
The clinic uses pharmacotherapy (medicines) and offers psychological support to those who wish to stop smoking. The pharmacotherapy is designed to minimize cravings, improve an individual’s ability to concentrate and perform their routine activities, and offer alternative solutions in the event that an individual has an irresistible desire to smoke. We do this with the use of nicotine replacement therapy (NRT), and drugs such as varencline and buproprion. These drugs offer an individual the same stimulation and pleasure that nicotine in a cigarette offers, without the innumerable cancer- and disease-causing substances that cigarettes offer. Such therapy is offered in a structured manner, with a target quit-date, and as a bridge for a pre-defined time. It is based on sound scientific evidence, and should be offered to all individuals keen to stop smoking.
The other component of the clinic is the behavioral and psychological support that we offer to individuals, recognizing and appreciating the strong behavioral component that is integral to smoking. Individuals will crave cigarettes when placed in environments that have been conducive to smoking in the past (with friends, while drinking beverages/alcohol, before using the washroom etc.), and behavioral therapy helps individuals cope with such situations with a certain thought structure and behavior modification. Each individual, in collaboration with the team, also creates her/his own written action plan that enlists the coping strategies to be employed in the event of an overwhelming craving in situations that can be anticipated to be associated with such cravings.
We also involve family in the process right from the first day, explaining to the family the nature of the addiction, the need to support, and not judge or criticize, and to treat the individual as a patient with a chronic disease, rather than an individual with a deficient control over one’s volition. By involving the family, we also encourage the individual to be forthright about the process, rather than consider it as a cause for shame and embarrassment to be carried out in a clandestine manner.
What is the success rate of smokers who quit by participating in the smoking cessation therapy?
While we haven’t formally analyzed our data, I would confidently guess that among individuals who adhere to the program, the success rates are around 80 percent. There is a proportion of patients who do not follow-up, and when contacted report having stopped smoking, and do not, therefore, feel the need to follow-up, and it is difficult to know whether these individuals have actually stopped smoking.
What are some of the difficulties associated with quitting smoking?
Nicotine is a highly addictive chemical, and causes severe withdrawal reactions, the severity of which depend on the degree of addiction. Individuals who start smoking in their teens, smoke more than a pack a day, and need to smoke their first cigarette soon after waking up are more likely to be severely addicted, and will therefore experience stronger withdrawal reactions if they try to quit cold turkey. These reactions include extreme irritability, and inability to concentrate, a constant craving for cigarettes, mood swings, a constant sense of fatigue, and sleep disturbances.
From Time magazine (The Future of smoking): “Almost nothing, not even heroin or cocaine, is more addictive than nicotine. While other drugs impair, nicotine enables. When you are sleepy, it wakes you; when you are anxious, it relaxes you; when you are hungry, it takes your hunger away. Heroin withdrawal causes unbearable flulike symptoms, but they eventually pass. People who’ve used both say it is harder to quit smoking. For quitting smokers, withdrawal is psychologically damaging; they feel anxious, depressed, irritable, bored and unable to focus. Even though half of smokers will die a slow and painful death from smoking, the 69% of smokers who say they want to quit know the odds are against them.”
What if efforts to quit result in relapse?
Relapse has to be dealt with in the same way as we deal with patients not taking their medicines for other chronic illnesses. For example, if a patient with diabetes stops taking their medicines (a not-so- uncommon scenario), and is admitted with a complication of the diabetes, we identify the barriers and facilitators to the patients adherence to treatment, educate the patient again, re-emphasize the need for treatment, and offer ongoing support. This is exactly the concordant, non-judgemental, scientific, patient-centric approach that we have toward individuals who have a failed attempt at stopping to smoke. It is important for both physicians and patients to not give up , and realize that every attempt is a fresh start, and the failure of the previous attempt is in no way a predictor of recurrent failure.
How long does it take a heavily tobacco dependent patient to quit smoking?
Stopping to smoke is not a function of dependence, and happens in an instant. However, like most addictions, the initial three months after one ceases to smoke are the most challenging, and need close monitoring and support. The risk of relapse is a function of time, and is highest in the first month, and progressively decreases with time.
Does cancer risk change after quitting smoking?
It certainly does. Although it never returns to levels identical to individuals who have never smoked, it consistently and progressively decreases with time.
Could you list out the specific diseases associated with smoking?
The chemicals in a cigarette affect almost every part of the body. Apart from cancers of the aforementioned organs, cigarette smoking is unequivocally associated with cardiovascular disease (high blood pressure, heart disease, stroke, renovascular – kidney disease). An under-appreciated and extremely serious disease associated with smoking is chronic obstructive pulmonary disease (COPD). COPD is an asthma-like disease that affects individuals who smoke, often years after they stop smoking. The disease is progressive, caused shortness of breath, limits the quality of life of the individual, and is associated with multiple comorbidities. COPD kills half a million people in India every year, more than those who die due to tuberculosis, malaria or HIV-AIDS. These numbers are expected to grow by 160% over the next 2 decades, in contrast to the decline in the number of deaths anticipated due to malaria, TB or HIV-AIDS. Individuals who smoke are also more likely to develop and die from tuberculosis, a disease that is highly prevalent in India.
Why do people begin to smoke?
Smoking initiation is often a pediatric/adolescent issue. Most children/adolescents begin smoking as part of experimentation that is common at this age. The tobacco industry invests huge amounts of advertising revenue in glamorizing smoking, and the sense of independence/glamour associated with smoking are often craved by adolescents going through the phase of creating an independent and rebellious persona. Pressure from peers and fear of ridicule from peers also encourages risk-taking behavior.
What are the differences between men and women regarding smoking? And quitting?
Women have smaller lungs than men, with narrower air passages, and less respiratory muscle power. Consequently, the density of particles deposited in a female lung per cigarette is higher in women than men, and women are more vulnerable to the effects of cigarette smoke as compared to men. The peak of the smoking epidemic in women across the world parallels the emancipation and empowerment of women, and advertising by the tobacco industry has constantly reinforced the association of smoking with empowerment (“You've come a long way baby”, “Now available in stiletto” are some of the slogans that have been by cigarette companies to entice women). Consequently, it is expected that the peak of this epidemic among women is developing nations has not yet been reached.
Women are more efficient at breaking down nicotine than men, but not at excreting it. As a result, women often have been found to inhale deeper and hold their breath for longer durations than men, possibly to sustain high levels of nicotine. Consequently, women have higher levels of cigarette-associated toxins in their lungs and blood stream, and find it more difficult to quit smoking than men.
What is the prevalence of tobacco consumption in urban India today?
It is estimated that close to one-fourth of the Indian population uses smokeless (chewing) tobacco. There was a 34 percent excess mortality among women, and 17 percent excess mortality in men that was attributable to the use of chewing tobacco. Based on a meta-analysis, the total number of deaths attributable to chewing tobacco in India annually is estimated to be 368127 (217,076 women and 151,051 men). In a nationally representative study it was estimated that in 2010 smoking would cause about 930,000 adult deaths in India; and about 70 percent of them between the age 30–69 years.
In addition to approximately 21 percent of the population that exclusively uses smokeless tobacco, the Global adult tobacco survey (2009-2010) estimated that 9% Indians are current smokers, and 5 percent use both forms of tobacco. This corresponds to roughly 275 million tobacco users in the country.
How many deaths are reported every year due to smoking?
It is estimated that 600,000-700,000 deaths in India were caused by cancer in 2012, with over 1 million new cases diagnosed every year. 20-50 percent of these cancers are tobacco-related cancers, i.e. tobacco is a known contributor to the development of such cancers. A nationally sampled study in 2010 showed that smoking caused about 20% of all deaths among males aged 30 to 69 years.
What are the three key messages you would like to convey to people who have tried to quit smoking many times before, but not succeeded?
a. With the current medical knowledge and treatment options that we have, trying to quit smoking by oneself is the equivalent of trying to control diabetes with diet alone: while it may be successful for some individuals, the majority will not succeed, and these individuals should not assume that a lack of willpower or determination was a cause of their failure.
b. Seeking help is not a sign of weakness. It is a sign of being an empowered and educated person, willing to accept the addictive nature of nicotine, and therefore, the need to counter the chemical with the right techniques and medication.
c. Stopping to smoke is a work in progress, and like any work in progress, it needs constant effort and self-realization. It is a journey; one that can be made more comfortable with the right companions and tools for the journey.