Tobacco Cessation and Counseling

INTRODUCTION

The tobacco epidemic is one of the biggest public health threats the world is currently facing, killing more than 8 million people per year around the world. More than 7 million had died due to direct tobacco use while around 1.2 million non- smoker died because of exposure to second-hand smoke. Over 80% of the 1.3 billion tobacco users worldwide live developing countries, where the burden of tobacco-related illness and death is highest. Tobacco use contributes to poverty by diverting household spending from basic and fundamental needs such as food and shelter to tobacco.¹

India is the second largest consumer of tobacco. According to GATS-2 reports, 28.6% of the population consume tobacco in any form, 10.7% smoke, and 21.4% use smokeless tobacco. Khaini (a form of smokeless tobacco) and beedis are the dominant forms of tobacco consumed in India, at 11% and 8%, respectively. By comparing GATS 2010, there has been a 6% decrease in the tobacco consumption recorded in GATS 2017 and also the NFHS-4 has shown decrease in the graph of prevalence rate as compared with NFHS-3. There has been increase in 1 year in the initiation of tobacco use in GATS-2 compared with the previous survey. However, between NFHS-3 and NFHS-2, during the gap of 7 years, all forms of tobacco consumption had increased; greatest numbers were seen in between 15 to 24 years. The annual growth rate of tobacco consumption is 2% to 3%.²

Smoked form was consumed by 14% of the population. On an average, Indians smoked about 6.2 cigarettes per day; this is the lowest of all countries, but among women, although the prevalence of cigarette smoking was less, the mean cigarettes per day were quite high, about 7, higher than the average of men, which was 6.1.In India, beedis accounted for the largest proportion of smoked tobacco consumed, especially among the lower socio-economic group, they consume beedis 8 to 10 times more than cigarette smoking. A study that assessed trends in beedi and cigarette smoking in India from 1998 to 2015 showed that beedis had been replaced by cigarettes among men due to rising income and increased affordability; that was significantly noticed among the lower socio-economic status groups.³

Regarding smokeless tobacco, India has the largest number of smokeless tobacco users in the world. Out of the 346 million global consumers, India alone has 80.8 million smokeless tobacco consumers, and there has been definite increase in smokeless tobacco across all age groups. Trends in age-specific standardized prevalence of smokeless tobacco use in India showed that consumption of smokeless tobacco increased with age for both the sexes. Moreover, smokeless tobacco use is considered as a common smoking cessation method and a study showed that 34.4% of smokers switched to smokeless tobacco from smoking tobacco use as a cessation method.⁴

Secondhand smoke (SHS) exposure is a significant problem in India, at both indoor and outdoor. A study has shown that 70% to 80% of the male smokers regularly smoked in home; 3 in every 10 adults working indoor are exposed to SHS. In home, SHS exposure has been seen especially high among children.⁴

Tobacco is also seen to be the leading cause for non-communicable diseases (NCDs); mortality due to NCDs accounts to approximately 63% of total tobacco users out of which approximately 80% of the deaths occur due to NCDs occur in low and middle income countries (LMICs) and 50% of these deaths occur in the age group of 30 to 69 years accounting 12% of the total tobacco users death in people who are above 30 years (WHO).⁵

Among smokers who are aware of the adverse effects of smoking, 3 out of 4 individuals are interested in quitting. One of the most important responsibilities of a countries health care system is to treat nicotine dependence. This effort contains different methods such as individual behavioural counseling, group behavioural counselling, pharmacotherapy/ medications and quit lines/telephone counseling. The cost of these methods varies, however these methods are not equally effective. So, it is important to match the treatment method to the local and cultural context as well as to client’s current needs.⁶

So, it has become very essential for integration of tobacco cessation programmes with health and development programmes which can be very helpful in overcoming the barriers in tobacco control and decreasing the tobacco-associated burden.

THE PROBLEM OF NICOTINE ADDICTION: ITS DEPENDENCE AND WITHDRAWAL

Addiction to nicotine does not happen quickly, it develops gradually. Most smokers go through a series of steps from experimentation or trial to regular use on their way to be addicted. Particularly in the industrialized countries, most people get addiction to nicotine by smoking during their adolescent time. Evidence shows that around 50% of those who initially start smoking in the adolescent years continue to smoke for 15 to 20 years.⁷

Smoking is a highly efficient form of administration of drug. Inhaled nicotine enters through the lungs and moves into the brain within seconds through blood circulation. Due to rapid rates of absorption and entry into the brain, a strong feeling of “rush” occur and thus reinforcing the effects of the drug. In addition, nicotine accumulates in the body over the course of 6 to 9 hours of continuity of smoking and results in 24 hours of exposure. Arteriovenous differences in nicotine concentrations during cigarette smoking are substantial, with arterial levels up to 10 times as high as venous levels. The persistence of nicotine in the brain throughout the day and night lead to change in the structure and function of nicotinic receptors, thus stimulates the intracellular processes of neuroadaptation.⁸

Withdrawal produces a series of symptoms that tobacco users may experience when they stop tobacco use suddenly. Withdrawal symptoms may vary but include a craving for nicotine, irritability, frustration or anger, anxiety, depression, diversion from concentrating, restlessness, and increased appetite (which can lead to weight gain). Most symptoms reach to maximum threshold post 24 to 48 hours after cessation and then gradually diminish over a period of few weeks. Some withdrawal symptoms may persist for months such as dysphoria, mild depression, anhedonia and increased appetite.⁹

Dependence is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

1. Tolerance
2. Withdrawal
3. Taking larger amounts of the substance or over a longer period than was intended.
4. A persistent desire for or unsuccessful efforts to cut down on substance use.
5. A great deal of time being spent in activities necessary to obtain or use a substance.
6. Abandonment or reduction of important social, occupational, or recreational activities because of substance abuse.

Withdrawal symptoms are also related to the degree of dependence, and they may increase temptations to smoke and alleviate the withdrawal, especially within the first 30 days after cessation. Withdrawal symptoms can be present, persist in a milder form, when a smoker reduces the number of cigarettes smoked or switches to a low-nicotine cigarette. Cravings can persist for months, especially if triggered by situational cues.^10,11

UNDERSTANDING THE CHALLENGES AND OPPORTUNITY OF TOBACCO CESSATION

Studies from India have shown that health education and community awareness has significantly helped in tobacco cessation. The existing TCCs are not sufficiently equipped to take care of any population-based cessation scale-up programme. In low-resource settings, with limited access to pharmacotherapy, there is also a need to evaluate cost-effective behavioural interventions, particularly for smokeless forms of tobacco use, for further expansion of tobacco cessation activities.¹²

Thus, tobacco cessation activities clearly need to be up-scaled, and the public better informed of the availability and relevance of such interventions. Younger persons using tobacco, women users, rural populations and the economically under privileged need to be more actively targeted. The integration of tobacco cessation with existing national health programmes is a cost-effective strategy to widen the cessation services for effective outreach at the community level. The use of innovative technologies like mobile phones and setting up quit-lines can give a major challenge to the current efforts of the Government of India for providing cessation facilities to a greater population, especially in the remote and rural areas. Thus, integration of these services into the health care delivery system still remains a challenge.¹³

APPROACHES TOWARDS TOBACCO CESSATION

Tobacco cessation methods can be broadly classified into:

1. COGNITIVE BEHAVIORAL THERAPY (CBT)

Brief advice/interventions

A variety of behavior therapies, ranging in complexity from simple advice offered by a physician or other health care provider or much more extensive therapy offered by counselors, have been shown to be efficacious for tobacco cessation.

One of the most effective non-pharmacological interventions for smokers strongly motivated to quit is by providing behavior support beyond scheduled clinical care by appropriately trained counselors.

The 5A‘s approach assists initially in identifying smokers by encouraging health professionals to ‘ask’ patients/clients whether they smoke/use tobacco. If they smoke, then ‘assess’ –whether willingness to stop smoking, then should ‘advise’ on the importance of quitting, should offer ‘assistance’ in the form of pharmacotherapy and/or referral for behavioural support, and finally should ‘arrange’ a follow-up appointment, if possible, with those patients who wish to stop smoking advice works primarily by triggering a cessation attempt.¹⁴

Strategies for Tobacco Cessation – Clinical Practice Guidelines: The 5-A‘s and 5-R‘s:

The five A‘s: Ask, Advise, Assess, Assist and Arrange and five R‘s: Relevance, Risk, Rewards, Repetition, Roadblocks is a five to fifteen minute approach that has proven global success.

Individual behavioral counseling

This type of counseling involves scheduled face-to-face appointments with a trained smoking cessation counselor. In addition to other behavior change techniques, motivational interviewing is generally incorporated into this form of behavioral intervention and is designed to enhance a person‘s impetus to change their behavior. This patient-centered approach enhances an individual‘s motivation for change through self-examination and identification of ambivalence to change and the subsequent resolution leading to sustained positive behavior change.

Group behaviour therapy programs

This form of therapy is offered to small groups of clients, and information, advice and, in most cases, behavioural intervention is provided. Group support allows individuals to learn behavioral techniques, and group participants provide peer support. The chances of quitting are doubled for those who attend group behavioral programs compared with those who receive self-help material but no face- to-face behavioral support. It is currently unclear whether groups are more effective than individual counseling.¹⁵

Telephone counseling/ quitlines

Quitlines are telephone-based tobacco cessation services. Since the late 1980‘s, quitlines have been established in many countries, states and provinces. Most are accessed through a toll-free telephone number and provide a combination of services including educational materials, referral to local programs, and individualized telephone counseling. Counselors answer callers‘ questions about the cessation process and help them develop an effective plan for quitting. Reactive quitlines only respond to incoming calls. Proactive quitlines handle incoming calls and also follow up the initial contact with additional outbound calls, to help initiate a quit attempt or to help prevent relapse.

2. INTENSIVE CLINICAL INTERVENTION

Brief advice from a heath care provider is recognized as an important motivator for a quit attempt. However, the 5A‘s approaches to minimal intervention stress the importance of assisting clients to make a cessation attempt. This may include more intensive behavioural therapy. A range of more intensive behavioural methods has been used in clinical settings to support patient attempts at smoking cessation.

These include:

a) Individual counseling

b) Supportive group sessions

c) Aversion therapy

3. PHARMACOTHERAPY

Types of available pharmacological interventions for smoking cessation have been demonstrated with behavioral support.

First Line of Drugs

NRT (Nicotine Replacement Therapy):-

NRT increases abstinence rates by 2 to 3 times that of placebo. All pharmacotherapy treatments approximately double the cessation rates. Therefore, patient preference and prior experience is the basis for treatment choice.

NRT is not advised for patients in immediate post myocardial infarction (within 4 weeks), patients with serious arrhythmias, worsening angina pectoris, or pregnant and lactating women. NRT works by supplanting nicotine from cigarettes and relieving or preventing nicotine withdrawal symptoms. Non-NRT alters or alleviates withdrawal symptoms as well.

Nicotine gum

Nicotine gum (Nicotine Polacrilex, Nicorette) has been available by prescription since 1985 and over the counter since 1996. Appropriate patient education is required for optimal use of the nicotine gum. Chew the gum until a pepperyl taste or tingling sensation occurs, then park the gum between cheek and gum, to facilitate nicotine absorption through the oral mucosa. Repeat the process of intermittently chewing and parking for about 30 minutes. Daily, patients may chew up to 30 pieces (2 mg) or 20 pieces (4 mg) of the gum. Over-the-counter gum labels recommend chewing 1 to 2 pieces per hour. Start most smokers on 2 mg gum. General guidelines are: use the 2 mg dosage for smokers who smoke fewer than 25 cigarettes per day, and the 4 mg dosage for smokers who smoke at least 25 cigarettes per day.¹⁶

Nicotine patch

The nicotine patch is available in several formulations that vary in strength and duration of action. Patches are worn for 16 or 24 hours per day. The 24-hour patch has the advantage of controlling morning smoking urges by producing higher blood nicotine levels upon awakening. The 24-hour patch may be associated with sleep disturbances, but the 16-hour patch is not.¹⁷

Starting doses are 21 to 22 mg (24-hour patch) and 15 mg (16-hour patch). Treat most light smokers with a standard dose patch, 21 to 22 mg/24 hours. A new patch is applied each morning on a hairless location between the neck and waist. After 4 to 6 weeks the dose is tapered to half of previous dose i.e.14 mg/24-hour. Following an additional 2 to 4 weeks, apply the lowest dose 7 mg/24 hour to complete the taper. The duration of patch use ranges from 6 to 12 weeks, depending on specific patient characteristics (e.g., prior experience with the patch, amount smoked and amount of nicotine dependence).¹⁷

Nicotine nasal spray

Nicotine nasal spray (Nicotrol NS) was approved in March 1996 for prescription use. The nasal spray delivers nicotine more rapidly than gum, patch or inhaler, and mimics the nicotine bolus from cigarettes. Smokers use 1 to 2 puffs per hour for 3 months. One spray of 0.5 mg into each nostril equals one dose of 1 mg. Patients may use 1 or 2 doses per hour, not to exceed 5 doses per hour or 40 doses per day. An average smoker uses 15 doses per day, decreasing the dosage over time. The medication is sprayed against lower nasal mucosa. It should not to be sniffed, swallowed, or inhaled.¹⁸

Nicotine inhaler

The nicotine inhaler (Nicotrol Inhaler) has been available in prescription form since 1998. The inhaler may be the best choice for smokers that need a substitute for the hand to mouth behaviour, and the tactile/sensory stimulation that cigarettes provide. It is also effective as a combination therapy with other NRT agents and bupropion. The ―inhaler‖ designation is a misnomer. The device does not deliver nicotine to the lungs. Each puff on the inhaler delivers 13 mg. To receive levels similar to most cigarettes, over 20 minutes, 80 puffs are needed to get 2 mg of nicotine.

Nicotine Vaccine

• A novel approach to assist in smoking cessation is the development of a nicotine-specific vaccine.
• Attaching nicotine to a suitable antigenic protein stimulates formation of antibodies (Nic-IgG) that has a high affinity and specificity for nicotine.

Non-NRTs

Bupropion Hydrochloride

Since 1998, bupropion hydrochloride (Zyban) has been available as an aid to smoking cessation by prescription. Bupropion is an aminoketone antidepressant that weakly inhibits both noradrenergic and dopaminergic uptake. It is believed to work based on the dopaminergic activity affecting the mesolimbic system and nucleus accumbens, which is the pleasure reinforcing area of the brain for addictive drugs. It also affects the noradrenergic activity in the locus caeruleus, which activates higher cortical functions such as alertness, concentration and memory. Lack of norepinephrine stimulation with nicotine withdrawal may account for withdrawal symptoms.¹⁹

Varenicline

Varenicline is the most recent drug developed for specific use in smoking cessation. It has a different mechanism of action to the other available smoking cessation products and appears to be an improvement on existing treatments for tobacco dependence. It is designed to work on the same receptor in the brain as nicotine to help relieve the craving and withdrawal symptoms associated with giving up smoking, while at the same time block the satisfying effects of nicotine. A total treatment duration of 12 weeks is usually recommended. If a patient who has managed to stop smoking at the end of the treatment period lacks confidence about remaining abstinent, it is worth considering treatment continuation, bearing in mind the high smoking relapse rates. Results of a long-term safety study indicate that varenicline is well tolerated and has a favorable safety profile for administration of up to 1 year.²⁰

Second Line of Drugs

Clonidine & Nortriptyline

Clonidine is a centrally acting α2-adrenergic agonist that dampens sympathetic nervous system activity. A small number of trials have shown that clonidine may be effective in promoting smoking cessation, but prominent side effects limit its usefulness for this purpose.

Nortriptyline is a tricyclic antidepressant that blocks reuptake of norepinephrine and serotonin. Dose :- 0.15mg – 0.75mg per day for 3-10 weeks.²¹

4. OTHER FORMS OF THERAPY

Acupuncture

Acupuncture as an aid to smoking cessation has been the subject of a number of controlled studies. Two meta-analyses have reviewed the results of controlled studies (While et al, 1990, Flore et al, 2000). There was no significant difference between active acupuncture and inactive acupuncture procedures.²²

Hypnotherapy

Hypnotherapy as an aid to smoking cessation has been the subject of a number of studies, including some controlled trials but the Cochrane systematic review (Abbott et al, 2002) concluded that there was such heterogeneity between methods and results that a meta-analysis of the literature was not possible at that time. The review concluded that hypnotherapy does not show a greater effect on six month quit rates than other interventions or no treatment.²²

Yoga therapy

Tobacco smoking remains the leading preventable cause of death across the world. Exercise has shown promise as an aid to smoking cessation because it reduces weight gain and weight concerns, improves affect, and reduces nicotine withdrawal symptoms and cigarette craving. Studies have shown that the practice of yoga improves weight control, and reduces perceived stress and negative affect. Yoga practice also includes regulation of breathing and focused attention, both of which may enhance stress reduction and improve mood and well-being and may improve cessation outcomes.²²

ROLE OF DENTAL HEALTH PROFESSIONALS IN TOBACCO CESSATION

As health professionals, the role of dentist specifically the public health dentist is constantly expanding and can be as far reaching as a professional's imagination, sense of responsibility and efforts. This is attributed to their expertise in dental and oral matter; they are highly respected, trusted and influential community leaders in any society. Their voices are heard across a vast range of social, economic and political arenas. Thus, they constitute a "teachable moment" to the community and can perform a unique role in tobacco use cessation activities.²³

At the individual level

This is approached at chair side, where the dentists see the harmful effects of tobacco use and they spend more time with the patient than other physicians. They should use this time to counsel the patient by promoting the oral health and healthy lifestyles. This can be achieved through few minutes of focused talk during oral examination and make the patient aware and conscious of the harmful effects of tobacco use.²⁴

For those willing to quit the 5 "A" method should be implemented

1. Ask - about tobacco use at every visit,
2. Advise - non-users to never use tobacco and users to quit,
3. Assess - the patient's readiness to quit and the level of dependence,
4. Assist - with quitting,
5. Arrange - follow-up visits.

In the community level.

A public health dentist specifically can make an immense contribution in tobacco use cessation at the community level by various ways such as the following:

1. by acting as a role model by not using tobacco or by quitting successfully,
2. by performing individual or group meetings periodically about the importance of tobacco use cessation,
3. by developing and implementing school intervention models for tobacco cessation,
4. by displaying educational material during the out-reach programs or in the urban and rural health centers where most of the population visit to seek health care,
5. by writing articles about benefits of tobacco control policies and participating in talk shows,
6. by linking with NGOs to spread health awareness, bringing into limelight the success stories of tobacco use cessation which can help in enlightening the community perception about tobacco use.²⁵

ROLE OF DCI, GOVT. OF INDIA & MOHFW

In order to tackle the epidemic of tobacco in India the Government of India has taken proactive steps including adjusting and adapting the Framework Convention of Tobacco Control (FCTC) and enacted the “Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce Production, Supply and Distribution)” Act as a multi measure law from May 1st 2004.²⁶

In the pilot phase, tobacco control units were established in 18 districts in 9 states, in 2007-08 which was to be expanded to 12 more states. In 2002, the World Health Organization (WHO) in collaboration with Ministry of Health and Family Welfare, Government of India initially opened 13 Tobacco Cessation Clinics later expanded to 19 across the country. The fourteen tobacco cessation clinics (TCC) were set up in various departments like psychiatry (3), cancer (5), surgical (2), cardiology (1), chest diseases (1) as well as in a general hospital setting (1) and nongovernment organizational setting (1). Later the TCCs were subsequently expanded to five more Regional Cancer Centres (RCC) in 2005. NOHP and NTCP have joined hands to expand the reach of tobacco cessation services in the country in collaboration with the Dental Council of India.^27,28

The DCI established Tobacco Cessation Centres (TCC) in all the dental institutes in India in order to encourage and create interdisciplinary clinics in dental institutes across the country that contribute in tobacco control and protecting patients from public health problems. The Tobacco Cessation Centers helps patients who want to stop using tobacco or patients interested in learning more about tobacco cessation. Certified tobacco cessation counsellors provide one-on-one counselling for all patients interested in quitting tobacco. Complimentary materials and cessation tools, such as nicotine patches, lozenges, and/or gum are provided to qualifying patients at no cost.²⁹

The TCC should be under the department of public health dentistry/department of oral medicine and radiology. Strong built-in referral system would be established with other dental and medical departments.²⁹

1. 1st chain of referral:- strong protocol for the referral chain would be developed amongst various departments in the dental college mainly oral medicine and radiology, department of public health dentistry, department of periodontology and department of oral surgery.

a. Clear, short and simple guidelines should be developed for referring a patient along with information of the location and timing of the centre.

b. TCC posters should be the displayed in all areas that clearly mention location and timing of the center.

c. Staff, post graduate students and interns should be oriented regularly.

2. 2nd chain of referral:- All dental colleges in India affiliated either to medical colleges or medical hospitals where various departments like community medicine, pulmonary medicine, preventive cardiology, psychiatry and ENT should be linked to TCC.

3. 3rd chain of referral:- All TCC should display the mCessation Programme- quit tobacco for life 011-229901701 and National Quitline Number 1800-11-2356.

There should be adequate space along with comfortable sitting arrangements, free from external sounds and distractions with adequate storage space for maintaining medical records. The TCC should have sufficient space for display of posters and other materials and provisions for electric supply, telephone and internet facility as well as common access for toilet and drinking water facilities.²⁹

Thus dental institutions can be instrumental in rendering behavioural and pharmacological interventions along with dental care to facilitate changes in tobacco user’s behaviour. It will also strengthen the role and strategies of the DCI and National Tobacco Control Programme, Ministry of Health and Family Welfare and Govt. of India in promoting tobacco control and rendering tobacco cessation services in India.

Finally, tobacco control efforts are more likely to be bolstered when incorporated into existing national-level, state-level and district-level health structures linked with current positions and accountability processes. The attempt to do so under the National Tobacco Control Program must be sustained and strengthened.

REFERENCES