BY: Dr. Sagrika Grover
(Public Health Dentist)

Demographic and epidemiological transitions and changes in lifestyle are leading to the emergence of cancer and other chronic diseases as public health problems in India. Cancer pattern in India reveals the predominance of tobacco related cancers, which are amenable to primary prevention. Cancer Registries in different parts of the country reveal that majority of cancer cases present in an advanced stage and makes treatment options prolonged and expensive. Therefore, the National Cancer Control Programme has placed its emphasis on prevention, early detection, enhancement of therapy facilities and provision of pain and palliative care. Health care personnel have a major role in providing awareness, promoting early detection, prompt referral to a cancer treatment facility and in providing pain relief and palliative care. TOBACCO CONTROL IS A KEY PART OF THE SUSTAINABLE DEVELOPMENT GOALS, MAKING SWIFT AND FULL IMPLEMENTATION OF THE WHO FCTC (Framework Convention on Tobacco Control) MORE URGENT THAN EVER.

The World No Tobacco Day (WNTD) 2021 theme and year-long global campaign ‘Commit to Quit’ provides a welcome focus on providing essential support to tobacco users to become tobacco free and begin the path to better health. It is particularly pertinent for smokers for whom the COVID-19 pandemic has been a motivator to quit, and to support those struggling with additional social and economic stressors imposed by the pandemic. The emphasis on providing social support through digital communities is timely while many people continue to cope with, and recover from, the trauma of enforced and prolonged social isolation. However, in promoting this vital component of tobacco control, the focus on individual behavior change must not obscure the fact that governments in almost every country give the tobacco industry exceptional treatment, by allowing continued sale of their lethal products.

As tobacco use is a health, social, economic and human rights issue, the benefits of successful cessation accrue beyond the individual, most immediately and directly through reduced involuntary smoke exposure and tobacco-related poverty for household members. Globally, non-smoking women and children are disproportionately affected by others tobacco use. The provision of effective tobacco use cessation treatment is a necessary component of government’s human rights obligations, yet of the seven WHO Framework Convention on Tobacco Control (FCTC) MPOWER tobacco measures (Monitor, Smoke Free Environments, Cessation Programmes, Pack Warnings, Mass Media, Advertising bans and Taxation), it is the one with the lowest proportion of countries which have implemented it at best-practice level.
Tobacco may be smoked (in the form of cigarettes, beedis), chewed (as gutka, khaini, etc), and inhaled as snuff. Cigarettes and other forms of tobacco are addictive because of the presence of nicotine. Nicotine blood levels achieved by smokeless tobacco use are similar to those from cigarette smoking. The role of nicotine in the compulsive use of tobacco products is now known to be equivalent to the role of cocaine, ethanol and morphine.
Stages of Development of addiction-
The initiation and development of tobacco use among children and adolescents progresses in stages:
Forming Attitudes and Beliefs about Tobacco 2. Trying Tobacco 3. Experimenting with Tobacco 4. Regularly Using Tobacco 5. Becoming Addicted to Tobacco. This process generally takes about 3 years.

For effective tobacco control, various factors like education, legislation, regulation, enforcement, taxation and other fiscal measures, economic alternatives, support for cessation, and community mobilization are important in regulating demand reduction and reduction of supply of tobacco in an effective manner.
Interventions at the national level:
● A rational tax structure needs to be designed to provide a tax- and price-based disincentive for tobacco consumption in all forms, rather than merely transferring consumption from one tobacco segment to another.
● While taxes on cigarettes must be progressively increased, beedies and other tobacco products should be taxed at sufficiently high rates.
● Several countries, e.g., New Zealand, Australia and the USA, have used an earmarked ‘tobacco tax’ to generate financial resources for funding health promotion programmes and specifically designed tobacco control programme.
● India has used an earmarked beedi tax to provide several benefits to beedi workers. This concept needs to be extended as a dedicated tax or cess that will be utilized for resourcing tobacco control programmes.
● The regulation of tobacco products aims to progressively reduce the levels of harmful chemicals and alter their physical characteristics.
● While a potential for ‘harm production’ exists theoretically, it is as yet unproven in public health terms.
● A Scientific Advisory Committee on Tobacco Product Regulation (SACtob), established by the WHO in 2002, provides technical guidance on matters related to tobacco product regulation-limitations of testing methods, setting up of upper limits for toxic ingredients and their emissions.
● India needs to develop laboratory capacity for regulatory testing of tobacco products (both smoking and chewed tobacco products)
● To monitor and discipline the tobacco industry, it is essential to develop a National Regulatory Authority with a clearly defined mandate and adequate resources.
● Supply-side actions are complementary to demand-side measures to control tobacco consumption in India.
● Supply-side actions pertain mainly to crop substitution, trade restrictions, controlling smuggling and even banning of the product.
● It is feasible and viable for tobacco cultivators to switch over to alternative crops such as cotton, chillies, isabgul (plantago), cotton, maize, soyabean, sugarcane and potato.
● An in-depth market analysis is required to identify alternative crops.
● The government should provide assistance during transition, especially to poorer farmers, which include rural training, broader off-farm employment opportunities and assistance with crop diversification. Tobacco diversification needs to be considered within a broader developmental framework.

Coping with cravings – During your first few weeks without tobacco there are likely to be times when you want to light a cigarette or use tobacco. Here are some ways to cope with the cravings. Check off the ones that you find work for you.
o Take deep breaths. Smoking is relaxing because you’re breathing deeply and taking a break from your routine. Some people find it helpful to suck through a straw because it feels like a cigarette.
o Exercise. Being active boosts your mood and curbs cravings. It will also help keep you from putting on weight, which may be a concern. Take a brisk walk when you would ordinarily have a cigarette or use tobacco, such as the first thing in the morning or after dinner. Over time you’ll feel more fit and want to continue exercising.
o Relax. Find a way to relax that works for you—meditation, yoga, deep breathing, exercise. Spend a few minutes of quiet time by yourself each day. Close your eyes and picture yourself free of tobacco.
o Treat yourself to things that make you feel good. Using tobacco lifts your mood, so it’s a good idea to find other things you like to do: be with friends, take naps, read good books, watch funny movies, go to concerts. Fill your time with fun and relaxing things to do and people who make you happy. (But be careful not to overspend. And avoid alcohol.)
o Drink plenty of water and eat fruits and vegetables. Water and herbal tea will ease the cough and runny nose, while fruits, vegetables, and whole grains will help with your digestion.
o Don’t act on your cravings. The urge to use tobacco should pass within 10 minutes. Busy yourself with something else until the danger has passed. Take a shower if you have to, or get up and move around.

Pharmacotherapy for Tobacco Cessation – Pharmacotherapies can be divided into nicotine replacement therapy, and non-nicotine medications that have anti-craving effects. Pharmacotherapies have an empirical record of efficacy for nicotine addiction and numerous studies have shown pharmacotherapies to significantly improve long term-quit rates. Recent consensus recommendations by multiple authorities establish them as a component of the “standard of care” for intensive treatment of nicotine addiction. Evidence is mounting for use of pharmacotherapy for smokeless tobacco users as well. Pharmacotherapy should be considered for every patient. There is no absolute contraindication. Special consideration, however, is required for certain patient groups among whom one or more of the drugs may have deleterious effects: ● Pregnant/breast-feeding women: No agents are approved for these patients, but pharmacotherapy is generally considered less harmful than tobacco use itself. Quit attempts without pharmacotherapy — especially in light tobacco users — are initially preferred. ● Smokers with cardiovascular or pulmonary disease: Although all agents are generally safe, patients with these conditions should be specially cautioned not to use tobacco while using nicotine replacement. Care should be exercised with use of nicotine with patients who have had a recent myocardial infarction, experience severe or worsening angina, or have serious arrhythmias. ● Light smokers & Adolescents and youth – be sure that they are dependant and not just experimenting with tobacco.
Nicotine Replacement Therapy (NRT) is used to relieve withdrawal symptoms in tobacco users when trying to quit. However, it must be made very clear that NRT alone is not the answer. Behavior modification is an important aspect of any behavior change, especially tobacco cessation. The use of NRT allows individuals to focus on the behavioral aspects of quitting without experiencing severe withdrawal symptoms. After the acute withdrawal period, nicotine replacement therapy is gradually reduced so that little withdrawal should occur.

Non-nicotine pharmacotherapies – These include medications such as bupropion, varenicline and cytisine. These pharmacotherapies reduce cravings and withdrawal symptoms and decrease the pleasurable effects of cigarettes and other tobacco products.
Chances of quitting tobacco can be more than double with the right support.
Quitting tobacco has major and immediate health benefits.
Every country can use its existing systems and resources to ensure that tobacco users at least receive brief advice, which can help motivate and support successful quit attempts.

Let’s conclude by saying –
Replacing the smoke on your face with a smile today will replace illness in your life with happiness tomorrow. … &
Eliminate tobacco from your life before it kills you!

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