UP IN FLAMES : On World No Tobacco Day
“Men are more easily governed through their vices than through their virtues.”
― Napoleon Bonaparte
Men (Women) are also easily governed by their vices than by their virtues. There comes a point in every addiction when the habit overpowers reason and takes control. Which is why we need a yearly reminder of something as established as the dangers of smoking tobacco.
World No Tobacco Day was created by World Health Organization in 1987 to draw global attention to the tobacco epidemic and the health dangers it poses.
The theme for this year’s No Tobacco Day is “We need food, not tobacco”. This global campaign aims to promote alternative crop production and marketing opportunities among tobacco farmers
The Origin Story
The journey of tobacco starts as an innocuous plant, cultivated in the old Americas (as it was believed to possess medicinal properties), then continues with Christopher Columbus across the Atlantic to Europe, and finding its way through the Suez Canal with the Portuguese to our own Goan shores, growing into an erstwhile fashion statement, escalating into a full blown global health issue.
Tobacco has since been cured and purified in order to isolate its most effective and at the same time it’s most damaging essences and presented in increasingly attractive packaging and endorsed by even more attractive celebrities for use by our impressionable population.
The many faces of tobacco
Tobacco finds its way into our bodies in many forms-
- A) Smoked tobacco: Bidi (most commonly used form in our country), cigarette, cigar, chilum, hookah, hookli and dhumti.
- B) Smokeless (Chewed) tobacco: Paan, mawa, zarda, misheri, khaini, snuff, gudhakhu
Contents: A commercially available smoked tobacco preparation may contain upto 7000 constituents that release 250 compounds when burned, all of which have carcinogenic or toxic potential to varying degrees. The most important of these is NICOTINE, an alkaline compound which is responsible for tobacco dependence. Some other harmful constituents include aromatic hydrocarbons, phenols, cresols, benzpyrene, indole, catechol and trace elements like nickel.
The Statistic:
China is the largest producer and consumer of tobacco in the world. In 2018, about 26.6% of adults (aged ≥15 years; 308 million in total) were current smokers and 44.9% of adults (515 million) were exposed to secondhand smoke at home
267 million Indian adults (>15 yrs) that amount to 29% of all adults, are users of tobacco (Global Adult tobacco Survey India, 2016-17).
More than 1 million adults die each year in India due to tobacco use accounting for 9.5% of overall deaths
34.6% of adults (out of which 47.9% is males and 20.3% is females) are smokers
14% adults (out of which 24.3% males and 2.9% females) use smoking tobacco
The economics of smoking:
The economic costs attributed to tobacco use from all diseases in the year 2017-18, in Indians aged 35 and above is said to amount to INR 117341 crore (WHO factsheets).
The market analytics of tobacco industries in terms of profits made by them and the social and welfare costs paid for the consequences in terms of healthcare expenditures go deeper than the above statistic. For example, economists Willard G. Manning, et al argue ‘the lifetime external costs of a sedentary life-style are actually higher than the external cost of smoking..’
However, World Bank 1999 report on smoking epidemic concludes- …externalities (market failures created by external costs- particularly those pertaining to deteriorating social welfare) transform what would be private risks and costs of the smoker himself into social costs. Reducing tobacco consumption (or eliminating it) would increase net social benefits.
Effects on Health:
Tobacco in all forms has significant local and systemic effects.
Apart from the direct effects on the body, smoking acts as a major risk factor in worsening of pre-existing systemic conditions.
A review of studies by public health experts convened by WHO on 29 April 2020 found that smokers are more likely to develop severe disease with COVID-19, compared to non-smokers.
Smoking increases the incidence of infections and aggravates the progress and prognosis of infectious diseases in a dose-dependent manner.
Smoking and Oral Health Myths
EFFECT ON DENTAL PLAQUE: While smoked tobacco doesn’t directly cause increase in dental plaque (microbial biofilm) levels, it is found to correlate positively among users, who also tend to have poor oral hygiene awareness and insufficient maintenance.
EFFECT ON CALCULUS (TARTAR): Due to high alkalinity smoked tobacco results in rapid calcification of dental plaque to form higher amounts of calculus deposits.
EFFECT ON GINGIVA (GUMS) – Tobacco usage often results in fibrotic changes in the gums with rolled margins, and heavy melanin pigmentation (smoker’s melanosis) that masks the common oedematous inflammation which is associated with dental plaque. (Myth: Tobacco is good for itchy/bleeding gums) – Smokers with gingivitis also report lesser bleeding gums owing to significant vasoconstriction that further masks the actual breakdown occurring in soft tissues. – The hampered blood flow also affects healing process and should be taken into account while planning extractions/ oral surgical procedures. – By affecting the activity of leukocytes, (particularly neutrophils- the first line of defence of the gums), tobacco effectively hampers immune response to plaque bacteria thereby increasing susceptibility to periodontal breakdown that is often unresponsive/refractory to treatment.
EFFECT ON DENTAL DECAY (CARIES): Smoked forms of tobacco use results in heavily stained teeth and is found to be associated increased dental caries. (Myth: Tobacco reduces dental caries) The reduced buffering capacity of saliva in smokers and higher streptococcus mutans counts have shown to result in greater caries involvement. (Vellapelly et al, Cent Eur J Public Health 2007)
EFFECT ON ORAL MUCOSA: The contents of tobacco are known carcinogens resulting in keratotic changes in oral mucosa that progress to show cellular dysplasia and eventually malignancy. Smokers show tobacco stomatitis, nicotina palatini (smoker’s palate), hairy tongue, angular cheilitis.
E-cigarettes are battery operated devices that allow inhalation of vaporised products and were introduced to aid in smoking cessation. Their use, specially among young students, is on an alarming rise.
Apart from vaporised nicotine, cigarette smoke contains aerosolised compounds like tetrahydrocannabinol (THC), cannabidiol (CBD), and butane hash oils (also known as dabs) which can cause adverse health effects.
The 2019 cases of five previously healthy adolescents exhibiting respiratory deterioration when they reported to the Children’s Hospital of Wisconsin prompted the Wisconsin Department of Health Services (WDHS) and the Illinois Department of Public Health (IDPH) in collaboration with Centre for Disease Control (CDC) to investigate their condition and release their health alert notices.
Typical presentation of these cases was complaint of dyspnoea, non-productive cough, reduced oxygen saturation and tachycardia with blood picture showing leukocytosis (without eosinophilia) not responding to standard antibiotics.
The CDC recommended that persons not use THC-containing e-cigarette, or vaping, products, particularly from informal sources.
Break the chain:
The US Preventive services task force (USPSTF) recommends treating smoking status as a vital sign and recording smoking status/history for every health visit.
Agency for Healthcare Research and Quality has provided Clinical practice guidelines to for practitioners to educate and help patients to quit the habit-
ASK Ask about past and current smoking status ADVISE Educate about the risks of smoking and benefits of cessation
ASSESS Identify the current mental stage of the patient on trans-theoretical model
ASSIST Set a quit date and prescribe Nicotine replacement therapy/bupropion
ARRANGE Follow-up in 1 week and consider referral to a cessation clinic
THE TRANS-THEORETICAL MODEL This model is helpful in helping health care providers to understand at what stage the patient is in and what type of support is indicated in the subjects.
- Pre contemplation: Patient is not aware that the habit is a cause of the problem and has no intention of quitting. Here, the goal is to increase the awareness of the problem and guide them into contemplation stage.
- Contemplation: The patient is aware that the habit is the cause of the problem and intends to stop it within 6 months. The aim is to reinforce and encourage the patient to follow through with their intentions.
- Preparation: Patient intends to stop the habit within less than one month. Patients are most responsive. Adjunctive therapies are suggested.
- Action: Patient stops the habit and maintains early abstinence. Significant efforts have to be made to prevent withdrawal symptoms at this stage.
- Maintenance: The patient has stopped the habit for six continuous months. Efforts have to be made to prevent relapse.
Pharmacotherapy
Pharmacological interventions in aiding tobacco cessation includes Nicotine Replacement therapy (NRT) (in form of patch, gum, lozenge, inhaler or spray), Bupropion sustained release and Varenicline, all of which depend on patient’s motivation and compliance to be of any benefit.
Government undertaking
Given the social nature of the smoking pandemic, The Government of India launched the National Tobacco Control Programme (NTCP) in the year 2007-08.
NTCP objectives
- create awareness about the harmful effects of tobacco consumption,
- reduce the production and supply of tobacco products,
- ensure effective implementation of the provisions made under “The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003” (COTPA)
- help the people quit tobacco use through Tobacco Cessation Centres.
It still remains up to the individual hooked to the cigarette who has chosen to burn himself along with it, to make up his mind and avail all the help there is to kick the habit. Albert Camus hit the nail on the head when he wrote, “The truth is that everyone is bored, and devotes himself to cultivating habits.” It is too easy to pick up on a habit and a mountain of a task to get rid of it, but man is known to move mountains by faith.
So, this Anti-tobacco day let us wish and work for lesser nicotine filled lungs and more stain-free, healthy oral cavities.
Image sources :
Feature Image : Canva
Stages of change Image by Brendan McDonnell
Smoke Free Environments photo by Cristian Guerrero on Unsplash