Willpower is not enough to quit smoking

Prof. (Dr.) Dharmakanta Kumbhakar

(The writer can be reached at drkdharmakanta@yahoo.com)

Smoking tobacco products, including cigarettes, cigars, and pipes, is associated with more mortality and morbidity than any other personal, environmental, or occupational exposure. It is a common cause of addiction, preventable illness, disability, and death. It kills millions of people and ruins the health of millions more. High smoking rates contribute to a significant number of early deaths and high healthcare costs. Most smokers die prematurely. Smokers usually die six to ten years earlier than their non-smoking counterparts. Each year, about 8 million people die early worldwide as a result of smoking tobacco. In the USA, it has been estimated that more than five million years of potential life and 90 billion dollars of productivity are lost each year due to smoking. Each year, smoking kills about 1 million Indians.

Smoking tobacco dramatically increases the risk of developing many diseases. It is responsible for the majority of lung cancer and chronic obstructive pulmonary diseases, and most smokers die either from these respiratory diseases or from ischemic heart disease. Smoking also causes cancer of the upper respiratory and gastrointestinal tracts, pancreas, urinary bladder, and kidney, and increases the risk of peripheral vascular disease, stroke, and peptic ulceration. Moreover, news had come that smokers were more likely to develop severe diseases with COVID-19 compared to non-smokers. Maternal smoking is an important cause of foetal growth retardation.

In addition to the health hazards of mainstream tobacco smokers, there are risks associated with exposure to passive smoking or environmental tobacco smoke (ETS). Research shows that ETS increases the risk of lung cancer, ischemic heart disease, and acute myocardial infarction. Globally, about 6,00,000 people die per year from breathing second-hand smoke. The Environmental Protection Agency classified ETS as a known human carcinogen in 1992. ETS is especially hazardous for women, infants, and young children. It is a major cause of foetal growth retardation and sudden infant death syndrome. Young children in households with cigarette smokers suffer from an increased risk of respiratory and ear infections and the exacerbation of asthma.

When the ill-health effects of smoking were first discovered, doctors thought that warning people about the dangers of smoking would result in them giving up. An initial decline in smoking rates during that period suggested that these assumptions were correct, but in most countries of the developed world, this decline has since slowed or plateaued, while rates are increasing amongst young women and in many developing countries where tobacco companies have found new markets. Unfortunately, smoking among teenagers is increasing day by day. Worldwide, there are about 1.3 billion smokers. There are around 120 million smokers in India. About 35 percent of men and 3 percent of women smoke in India. There has been a spurt in the number of women smokers in India. Bidis account for nearly 85 percent of total smoked tobacco in India. Assam also has a growing number of people over 15 years of age who are addicted to smoking. According to the available data, in Assam, about 34.9 percent of the male population smokes tobacco.

In reality, there is a complex hierarchy of systems that interact to cause smokers to initiate and maintain their habit. Nicotine is an important constituent of cigarette smoke. It is an alkaloid that readily crosses the blood-brain barrier and stimulates the nicotine receptor in the brain. At the molecular and cellular levels, nicotine acts on the nervous system to create tobacco addiction and dependence, so that smokers experience unpleasant effects when they attempt to quit. So, even if they know it is harmful, the role of addiction in maintaining the habit is important. Influences at the personal and social levels are just as important. For example, research has shown that many individuals bolster their denial of the harmful effects of smoking by focusing on someone they know personally who smoked until he was very old, went to the pub every day, and died peacefully in his bed at home. Such strong counterexamples help smokers maintain internal beliefs that comfort them when presented with statistical evidence. Young female smokers are often motivated more by the desire to “stay slim” or “look cool” than to avoid an illness in middle life.

The majority of adult smokers say they would like to give up smoking, but only 2 percent of smokers manage by willpower alone. Even if a smoker decides to quit, there are a variety of influences in the wider environment that alter the chances of sustained success, including peer pressure, cigarette advertising, and finding oneself in circumstances where one previously smoked.

Health professionals can work with the individual smoker to understand his or her beliefs and motivate them to quit smoking. Motivation sessions in groups have also been shown to be effective. Nicotine Replacement Therapy (NRT) or the use of bupropion (an antidepressant that acts centrally) can reduce smoking.

The strategies commonly employed to stop smoking and their impacts are as follows: (1) Smokers who are not motivated to try to stop smoking: Record smoking status at regular intervals, provide anti-smoking advice, and encourage a change in attitude towards smoking to improve motivation. (2) Motivation for light smokers (<10/day): Anti-smoking advice and involvement in an anti-smoking support programme. (3) Motivation for medium smokers (10–15 per day): As above in point 2, plus NRT (minimum 8 weeks) (4) Motivation for heavy smokers (>15/day): As above in point 3, plus bupropion (when NRT and behavioural support are unsuccessful but the patient remains motivated).

If intensive support is combined with pharmacological aids, quit rates of smoking are significantly improved. Although the absolute quit rates seem modest, smoking cessation interventions are cost-effective and, if widely available, can contribute to a reduction in smoking prevalence. However, action at the societal level, such as bans on tobacco advertising, increasing taxation on tobacco products, regulation of the sale of tobacco products, making sure all workplaces and public places are smoke-free, placing clean and 85 percent pictorial warnings on cigarette packets, plain packaging, and the generation of awareness against tobacco-related health hazards amongst the public, may be more effective.