Up in smoke: Can that be your last cigarette?

Mathukiya wasn’t ignorant. The 30-year-old graphic designer from Surat was well aware of the health risks. Over the years, he tried to quit smoking multiple times but had little luck. Five years ago, things turned ugly. His withdrawal symptoms were severe: he went through a bout of anxiety and depression, his appetite suffered, and he grew so weak that he had to be hospitalized.

The good news is that he has been smoke-free for five months now. His journey is sort of a case study for those attempting to kick the habit. A plethora of products and programmes, old and new, promise to help smokers give up smoking. That market, globally, is in billions of dollars.

The world-wide market for cigarettes is just shy of a trillion dollars, whereas it is $12.7 billion in India, according to the data website Statista. The market research firm, Research and Markets, pegged the size of the global smoking cessation and nicotine de-addiction market at $20 billion in 2021. One estimate suggests that the size of the nicotine replacement therapy market (NRTs)—such as gums, patches, lozenges, sprays and inhalers—is ₹200 crore in India and fast growing. These businesses are poised to grow fast because India has a staggering number of smokers.

Every tenth Indian of 15 years of age or above smoked tobacco (mostly bidi or cigarette); nearly two in five smokers had attempted to quit at least once in the past 12 months, according to the Global Adult Tobacco Survey (GATS) 2016-17. However, barely half of them could sustain it for more than a month, showing how perverse smoking dependence is. Mathukiya, for instance, became a regular smoker within just two years, but it took him seven years to quit. Getting hooked is easy; getting off them isn’t.

The question, then, is: why is it so hard to quit smoking? The answer is layered.

The culprit

Nicotine—an addictive stimulant found in tobacco plants—sustains a physical dependence. It activates nicotinic receptors in the brain. Every time one smokes, nicotine attaches itself to these receptors, causing dopamine release, which in turn makes one feel good. A prolonged exposure to nicotine also causes desensitization of receptors, requiring smokers to smoke more cigarettes to keep the effect at a certain level. Nicotine level drops within one-two hours of smoking, making one crave for cigarettes again. Its absence for a longer period, during the quitting process, can cause withdrawal symptoms such as headaches, coughing, mood changes, decreased heart rate, etc.

There are 93 known harmful and potentially harmful chemicals found in cigarettes, with more than 70 of them causing cancer, according to the US Food & Drug Administration (FDA). While nicotine is addictive and can compromise the development of the brain and the foetus, it is among the remaining 23, giving it a somewhat ‘safe’ level compared to other cancer-causing chemicals found in cigarettes.

“People smoke for the nicotine, but they die from the tar,” wrote Michael Russel in a research journal in 1976. Russel, called ‘the father of tobacco harm reduction’, focused on developing effective treatment to help smokers quit.

Gums and patches

Over the years, NRTs flooded the market. NRTs release smaller doses of nicotine in the body, enough to manage cravings but they are free of tar and other harmful chemicals.

There are two non-nicotine prescription drugs (Bupropion and Varenicline) that are also recommended to help with effective quitting. Bupropion is an antidepressant and reduces the urge to smoke. Varenicline attaches to nicotine receptors in the brain without stimulating them as strongly as nicotine. By blocking the reward sites in the brain, it leaves fewer places for nicotine from a cigarette to attach, and it also triggers some dopamine release, thus keeping the withdrawal in control.

However, none of these therapies do to a smoker what a cigarette does—in terms of the sheer dopamine hit.

No wonder their success rate is rather modest. Only 6-8% smokers are able to quit using NRTs, suggests evidence. Mathukiya, for instance, tried quitting using Nicotex gum (manufactured by Cipla) for a month. He would chew it whenever he craved a cigarette. But the moment he smoked a cigarette, he would completely relapse. He disliked the taste of the gum and it gave him a sore throat often, so he eventually gave it up.

The effect can be slightly higher for the prescription drugs: 6-15%, show studies. They can have side effects, though, such as insomnia, nausea, dullness, weight gain, depression, etc.

Nonetheless, Bupropion, Varenicline and the NRTs are part of the World Health Organization (WHO)’s approved pharmacological therapies, also followed in India. Their dosage is gradually tapered off and phased out in 12 weeks.

To vape or not?

Another nicotine-based solution popular among many smokers trying to quit is vapes. They go by several other names—vaporizers, e-cigarettes, e-cigars—which are clubbed under electronic nicotine delivery system (ENDS).

The claim is that ENDS heat a solution, containing nicotine derived from tobacco as well as flavours dissolved in propylene glycol or vegetable glycerin and other ingredients, to create aerosol inhaled by users. ENDS are a way to co-opt nicotine dependence developed through cigarettes, but without the several other toxic chemicals present in them.

ENDS, however, are banned in about 30 countries, including India. The rationale is that nicotine, being a highly addictive substance, can provide an easy pathway to cigarette use among adolescents and the youth. There was an outbreak of e-cigarette or vaping use-associated lung injury (EVALI) in the US in 2019, causing 68 deaths until February 2020. This led to a widespread fear about ENDS. It is to be noted that EVALI outbreak was associated with cannabis-containing vapes, not nicotine-based products.

The other major argument against ENDS is that there is no clear evidence regarding its effectiveness as a smoking cessation aid. “We should wait for the evidence on whether it should be used as an alternative or not,” says Dr Saatvik Manchanda, resident doctor in pulmonary medicine at Vallabhbhai Patel Chest Institute in Delhi, advising caution.

Herbal ways

A company called Organic Smokes appeared on the second season of the TV programme Shark Tank India. The seven-year-old company is licensed by the department of Ayush in the Haryana government and sells herbal cigarettes—it blends in multiple flavours as chemical-free alternatives to tobacco-based cigarettes. Herbs used are basil, tea and mint leaves among others. “These herbs help in bronchitis,” claims Piyush Chhabra, co-founder of Organic Smokes.

“There are three routes of therapy recommended in Ayurveda: oral, injectable and smoke. The last is called dhumpana therapy,” says Chhabra. “A number of our consumers have cut down on their smoking after using our products,” he adds.

The recommended dose is one cigarette in four hours, which effectively is four cigarettes a day, assuming 16 hours of awake period, according to dinacharya (daily routine) specified in Ayurveda.

He argues that people have enjoyed smoking forever, as our text and scripture suggests, and the smoking industry is not going to end anytime soon. “If you can create healthier alternatives, then why not?” asks Chhabra. The company will soon launch herbal vapes.

The moot question here is if these alternatives are healthier? Chhabra cites Ayurvedic papers as valid evidence, saying no clinical trial is required if a paper trail exists.

“They should conduct randomized controlled trials (RCTs), not just rely on bookish evidence, before selling their products,” counters Dr Manchanda. “At this point, we can only be suspicious of their benefit in smoking cessation, but once you lose your health, there is no coming back,” he cautions.

Dr. Gopi Krishna Yedlapati, an interventional pulmonologist at Yashoda Hospitals in Hyderabad, says that organic vapes, if they don’t contain nicotine, might still be safe. The long-term exposure to smoke emitted by the combustion of herbs, on the other hand, can lead to lung diseases, he adds.

Another herbal product is Smotect from a company called Project Happiness. It is a nicotine-free herbal tablet that claims to not just help give up smoking but also improve lung capacity. The formulation contains kapikacchu, ashwagandha, haridra, tulsi, etc. The company claims to have conducted a randomized, double-blind study, showing 23% success rate in the intervention group, compared to 4% in placebo group, for complete cessation. While the results are encouraging, the study is yet to be peer reviewed. The tablet is recommended in three different doses depending upon the extent of smoking.

“We prepared this formulation after research of seven-eight years,” says Gurseet Singh, the founder of Project Happiness.

“Ayurvedic formulation should be personalized, based on the individual attributes of the body. Not sure, how one standard formulation is being used for everybody,” questions Ruhi Maheshwari, a clinical psychologist with around nine years of experience.

Mind over matter

After unsuccessfully trying to quit smoking abruptly and after using alternatives like Nicotex and dry salted ginger (there’s a myth it helps in kicking the habit), Mathukiya turned to mobile apps last year.

An abundance of apps act as a log, helping people delay the next drag by tracking their smoking behaviour, and update them on health changes. A mobile phone text-based government programme called mCessation sends personalized daily messages to those who are trying to quit. An evaluation conducted by the ministry of health and family welfare found an average quit rate of 7% for both smokers and users of smokeless tobacco.

Mathukiya chanced upon apps that tracked time and money saved from quitting. He found it a nuisance to regularly update his activity there.

Next, he learnt about QuitSure. “When I read the description of QuitSure, I got a vibe that it’s different,” says Mathukiya. The app asked me to continue smoking while I complete their course. Every app or platform asks me to quit. This app was asking me to smoke…so, I got curious,” he adds. The app offers a 6-day course, which Mathukiya took a month to complete.

It’s built to address craving, as psychological addiction is the mainstay of smoking addiction, says Ram Chandra, co-founder of QuitSure and an ex-smoker.

After studying the data, Chandra found that the most popular perceptions about smoking are that it “helps me relax”; “is fun”; “makes me sociable”; “helps bowel movement in the morning”, and so on.

QuitSure asks smokers to practice “mindful” smoking and asks them to rationally evaluate these thought patterns.

Mathukiya cites an example. “Let’s say I smoke to calm down when I’m angry. But does the anger subside because of smoking or because I moved away from the (unpleasant) situation? Spent some time alone while slowly breathing? That helped me realize things mindfully.”

QuitSure has helped around 50,000 people, Chandra claims. 72% of the users who had completed the programme were able to abstain for more than six months, revealed a follow-up survey involving around 1,000 respondents conducted by the company. “We are currently conducting a randomized control trial to get more conclusive data on the real efficacy in a clinical setting,” says Kriti Bajaj, co-founder of QuitSure.

The percentage the company cites is way higher than any pharmacological interventions. There are few reliable studies that measure the efficacy of psychological interventions alone, but evidence shows that they certainly improve the efficacy of NRT and prescription drugs. The current standard intervention is a combination of pharmacological and psychological treatment.

So, what explains the success of QuitSure if one were to trust the preliminary data?

Anant Agarwal, a consultant psychiatrist and founder of Perspective Psychiatric Centre, says that the success rate of QuitSure does not seem “very realistic” to him, and the data could have selection bias (in terms of the kinds of users) and reporting bias. “The success rate of cessation programmes for substance use disorder is usually 10% or less,” he informs.

Psychologists say that the concepts QuitSure uses appear to be based on cognitive behaviour therapy (CBT), which focuses on changing thoughts and beliefs to improve behaviour and emotional state, and rational emotive behaviour therapy, which helps get rid of irrational beliefs and negative thoughts.

These are valid techniques used in smoking cessation programmes. But they all raise a few questions. Ruhi Maheshwari, the clinical psychologist, says that she has not seen this kind of success in any rehab. “CBT, alone, takes a minimum of 12 sessions. Not sure how a six-day programme will work,” she ponders.

One approach suggests four CBT and four motivation enhancement therapy sessions for substance abuse, but these frameworks have to be further tweaked in the Indian context. “Patients often end up defending themselves for the first couple of sessions. By the time they acknowledge their dependence, their real struggle begins. It’s often a long process,” she adds.

The most important marker for success in smoking cessation is the motivation level of the user. Those signing up for an app-based programme are certainly a motivated lot. 42% smokers in India were not even interested in quitting, with only 8% showing an interest in quitting within a month, showed GATS 2016-17.

The other criticism is of the complete delineation of psychological addiction from physiological addiction. They are not independent, experts say.

“Any addiction needs to be addressed by identifying triggers, routine and reward,” says Prajakta Mishra, a clinical psychologist with over 10 years of experience. If someone’s trigger to smoke is reaching home tired after work, she or he would feel relaxed after smoking around 6 PM. They would need to find an alternative activity, like going to gym, to change this habit loop. The trouble is that visiting a gym, or any other activity, will never match the dopamine release from nicotine. That is why NRTs or drugs may be needed to manage withdrawals.

The trouble with addiction cases is that recovery has no end point—relapse can happen even after 20 years, says Maheshwari. Having said that, the first year since quitting is a critical period.

Smokers, therefore, ought to be extra vigilant in the first 12 months after they begin a therapy programme. Some psychologists also advice they delay major (emotional) decisions and investments during this time.