obacco use leads to life-threatening addiction, which damages almost every organ of the body. Cancer, cardiovascular diseases and chronic obstructive pulmonary disease are the main health issues associated with tobacco consumption. Pakistanis are among the world’s largest consumers of tobacco, and Pakistan ranks among the top fifteen countries in the world in terms of the disease burden associated with tobacco smoking. Vapers are also used as status symbols and fashion statements by the youth as well as adults. Electronic nicotine devices such as e-cigarettes, juuls, pods, e-hookas, e-pipes, and vape pens are also available in the market under different brand names. Some of these are available in attractive flavours.

Though conventional cigarettes are the mainstay worldwide, tobacco is also used in smokeless formulations easily available in local markets. Tobacco with various alkaline modifiers - khaini, naswar, gul – is also easily available. Tobacco with slaked lime and areca nut - gutkha, zarda, mawa, Manipuri and betel quid – is also widely used all over Pakistan.

The toxic effects of smokeless tobacco products are due to trace level contaminants present in these products. A research study done in Pakistan showed that a variety of toxic constituents and carcinogens such as cadmium, arsenic, lead and other carcinogenic metals, nitrite, nitrate and nicotine were present above their allowable amounts, making it a health risk for consumers. These smokeless products are contributing to oral cancer (the second most common cancer in Pakistan). Interestingly women consume more smokeless tobacco than men in our country. In 2017, its use led to an estimated 18,711 deaths due to cancer and ischemic heart disease.

In the national survey taken in Pakistan, 9,856 households were sampled. It was found that overall, 19.1 percent of adults were using tobacco. Among them, 12.4 percent smoked tobacco and 7.7 percent consumed smokeless tobacco. Exposure to second-hand smoke was seen in 86 percent of restaurants. It was 76 percent on public transportation. Current cigarette smokers spend Rs 500 per pack on average. On average, consumers take ten cigarettes per day and spend Rs 7,500 per month. Also, many consume chewable tobacco alone or along with smoking.

There is a dire need to devise a strategy for strict enforcement of relevant laws to reduce the tobacco burden in the country, which lay emphasis not just on smoked tobacco products but also on easily available smokeless tobacco substances.

In order to control the tobacco epidemic and protect the health of world citizens, the WHO recommends six evidence-based measures called MPOWER. These are monitoring of tobacco use and prevention strategies, protection of people from tobacco smoke, offering help to smokers for quitting, warning public about adverse effects of smoking, enforcing bans on tobacco advertisement and promotion; and raising taxes on tobacco products.

Though Pakistan has signed the agreement on tobacco control, there are issues with its implementation. Pakistan has failed to implement a no smoking policy in public places. There are no direct bans on advertising and promotion of tobacco on electronic media (television, radio) nor on billboards and banners. Services for helping smokers quit smoking are also limited. This is also evident from a very low cessation rate (1.8 percent) among males in the mentioned study.

Treatment for addiction

First-line treatment for smoking cessation in adults includes behavioural therapy with nicotine replacement therapy (NRT) and oral medicines. Although many of these products are available over the counter, it is best to consult a family physician or a psychiatrist.

Behavioural counselling options include text messaging, phone apps and web-based interventions. Physical contact sessions with trained personnel are also very productive.

NRT includes gums, patches, lozenges, inhalers and nasal sprays. Oral medicines varenicline and bupropion are also good choices. The recommended treatment is to use varenicline or a combination of two NRT products (e.g a patch and a short-acting gum/ lozenge). However, a single NRT can also be used.

Nicotine gums and lozenges are available in Pakistan. A 2mg or 4mg dose of either form is advised empty stomach every one to two hours. No food/ drink should be taken during gum use. Adverse effects include jaw soreness, nausea and heartburn. Not more than 24 gums and not more than 20 lozenges should be taken in 24 hours. Gums and lozenges are expensive. Each gum costs around Rs 35-40.

Nicotine nasal spray - one spray in each nostril every one to two hours – can also be used to cope with withdrawal symptoms. Nicotine patches are available to apply on the body. This provides a sustained level of nicotine and is easy to use. The user should begin its use before the quit date.

The advised nicotine replacement doesn’t increase the risk of cardiac events or developing cancer.

Oral medicine bupropion, used for depression, is helpful in smoking cessation too. The user needs to consult a physician or a psychiatrist as it is contra-indicated in certain medical conditions such as epilepsy. It has to be started 1-2 weeks before the quit date.

These first-line agents can be safely used by cardiac patients and those suffering from cancer. Although for patients with psychiatric illness, varenicline rather than NRT is suggested.

Does a smoking cessation programme increase the use of other substances in multi-drug addicted adults?

No. In fact, it has a positive impact on the use of other substances.

Can e-cigarettes be used for the treatment of tobacco dependence? No, they are deleterious to health.

Is there a proven role of alternative medicine in smoking cessation? There is insufficient evidence for alternative treatment options like hypnotherapy, acupuncture, financial incentives etc, although they have proved efficacy in certain clinical trials. Anyone interested in opting for these must consult a physician for advice.

Dr Naureen Kazim [MBBS, DFM, MCPS] is a senior registrar at Department of Family Medicine at Ziauddin Medical University, Karachi.

Dr Naseem Dhedhi [MBBS, FCPS, MRCGP(INT)], is a consultant in family medicine at Al-khidmat Raazi Hospital, CBR Town, Islamabad