Quitting Tobacco: Cigarettes, Naswar, Paan and Gutka

What tobacco does, in each of its forms

Nicotine is what makes tobacco hard to give up. It is not what does most of the damage. The harm comes from everything else in the product: in smoke, from tar and carbon monoxide and dozens of known carcinogens; in the chewed and placed forms, from tobacco-specific nitrosamines that sit against the lining of the mouth for hours at a time, and from areca nut, which drives its own separate disease.

Smoking accelerates the furring of the arteriesAtherosclerosisAtherosclerosis is the build-up of fatty, fibrous plaque inside artery walls, which stiffens them and narrows the channel blood flows through. It develops silently over decades and is the process behind most heart attacks and strokes.Read the full definition, which is the process behind heart attack, anginaAnginaAngina is chest discomfort that appears when the heart muscle is not receiving enough blood, typically brought on by exertion or emotion and eased within minutes by rest. It is a warning that a coronary artery has narrowed, rather than a heart attack in itself.Read the full definition and strokeStrokeA stroke is a sudden loss of blood supply to part of the brain, either from a blocked artery or a bleed. It is an emergency — treatment works only within a few hours of the first symptom.Read the full definition. It raises blood pressureBlood pressureBlood pressure is the force of blood against the artery walls, written as two numbers in millimetres of mercury: the higher one is the pressure as the heart squeezes, the lower one the pressure as it refills. It varies through the day, so a diagnosis is never made on one reading.Read the full definition and pulse with every cigarette, damages the small airways of the lung, and is the main cause of chronic obstructive lung disease. It worsens asthmaAsthmaAsthma is a long-term condition in which the airways are inflamed and tighten in response to triggers, causing wheeze, cough, chest tightness and breathlessness that come and go. It is controllable in almost everyone with the right treatment used correctly.Read the full definition, delays wound healing, hastens cataractCataractA cataract is a clouding of the eye's natural lens, which blurs vision gradually as though a clear window had frosted over. It is the commonest cause of avoidable blindness in Pakistan and is corrected by a short operation that replaces the lens.Read the full definition, contributes to thinning bonesOsteoporosisOsteoporosis is loss of bone density that leaves bones fragile enough to break from a minor fall or even a cough. It causes no symptoms until a fracture happens, which is what makes it dangerous.Read the full definition, reduces fertility in both men and women, and harms an unborn child when a pregnant woman smokes or lives with smoke.

The belief that costs the most lives here

Almost everyone who uses naswar, gutka or paan has been told, or has concluded, that because there is no smoke there is no serious harm. That is wrong in a specific and well-documented way. The International Agency for Research on Cancer, which is the World Health Organization's cancer research body, classes smokeless tobacco as a cause of cancer in humans, and classes areca nut as a cause of cancer in humans on its own, with or without tobacco added.

The practical consequence is visible in any dental clinic in this country. Oral submucous fibrosis begins as burning with spicy food and a change in the feel of the cheeks; over years the tissue stiffens until the mouth will not open more than a couple of centimetres. It is a chronicChronicChronic means long-lasting — a condition that has persisted for months or years and is managed over time rather than cured in a course. It is the opposite of acute, and it says nothing at all about how severe something is.Read the full definition condition, it is considered pre-malignant, and a proportion of cases go on to become cancerousMalignantMalignant describes a growth that can invade the tissue around it and spread to other parts of the body. It is the opposite of benign, which stays where it started.Read the full definition. Cancer of the mouth is among the commonest cancers in Pakistan, and it is one of the very few common cancers that is almost entirely preventable.

What happens after you stop

For chewers the timeline is different but the direction is the same: mouth lesions in the early stages often improve or stop progressing once the habit stops, and the risk of cancer falls year by year. Established submucous fibrosis does not fully reverse, which is the argument for stopping now rather than after the next check-up.

A method that works

1. Pick a date within the next two weeks and write it down. Not soon, not next month — a date. Choose one without a wedding, a deadline or a journey in it.
2. Decide it is a full stop, not a reduction. Cutting down slowly works for very few people; most drift back to the old amount within a month. Reduction is useful only as a run-up to a fixed quit date.
3. Tell the people you live and work with. Ask them not to offer, and ask anyone who uses tobacco not to use it in front of you for the first fortnight.
4. Clear the house, the car and your pockets the night before — cigarettes, naswar dabbi, sachets, ashtrays, lighters, the paan-daan. Leaving one packet in reserve is the commonest way a quit attempt ends.
5. Write down your five triggers. For most people these are chai, after a meal, driving, a particular friend, and stress. Decide in advance exactly what you will do instead in each of the five.
6. Arrange help before the date, not after the relapse. Nicotine replacement, a conversation with your doctor, or a counselling service — all of them work better started on day one.
7. Plan for cravings. A craving peaks and passes in about three to five minutes. Drink water, walk out of the room, chew saunf or elaichi, brush your teeth, call someone. It will pass whether or not you smoke.
8. Bank the money. Put the daily cost in a jar or a separate account where you can see it. A pack a day at around three hundred rupees is roughly nine thousand rupees a month; whatever your figure is, seeing it accumulate is unexpectedly motivating.

Withdrawal, and what actually helps

Expect irritability, difficulty concentrating, restlessness, low mood, increased appetite and disturbed sleep. These are at their worst in the first week, ease considerably by the third or fourth, and are a sign that the body is readjusting rather than a sign that you need tobacco. Many people gain some weight — commonly four to five kilograms over the following year — because appetite returns and metabolismMetabolismMetabolism is the whole set of chemical reactions a body uses to turn food into energy, build tissue and clear waste. It runs constantly, and most of it happens whether a person is active or asleep.Read the full definition settles. That weight gain is a fraction of the risk that continuing carries, and it can be managed once the quit is established.

Nicotine replacement therapy — patches, gum or lozenges — supplies nicotine without the smoke, tar and nitrosamines, and reliably increases the chance of a successful quit in trials. The right strength depends on how much you use and how soon after waking you use it, so ask a pharmacist or doctor rather than guessing. Two prescription medicines are also used for cessation, and whether either is appropriate, and at what dose, is a decision for a prescriber who knows your history, particularly if you have had depression or seizures.

If you slip

A single cigarette or one pinch of naswar is a slip, not the end of the attempt. What turns a slip into a relapse is the decision that the quit is now ruined. Note what happened, what the trigger was, and what you will do differently when it recurs, and carry on from the same day. Most people who stop for good have made several serious attempts first; each one teaches something about the triggers. The one thing that reliably fails is deciding you will try again in the new year.

Protecting the people around you

• Second-hand smoke causes chest infections, ear infections and worse asthmaAsthmaAsthma is a long-term condition in which the airways are inflamed and tighten in response to triggers, causing wheeze, cough, chest tightness and breathlessness that come and go. It is controllable in almost everyone with the right treatment used correctly.Read the full definition in children, and heart disease and lung cancer in adults who have never smoked.
• Do not smoke inside the house or the car. Opening a window does not make a room safe; a fan does not either.
• Smoke residue settles on clothes, upholstery and hair and is still there hours later, which matters most for infants.
• Do not send children to buy tobacco, and do not keep gutka sachets where they can reach them. Most lifelong users in Pakistan started before they were twenty.
• If you cannot stop yet, make the house and the car completely tobacco-free anyway. It is the single most useful thing you can do for your family while you work on the rest.

When to see a doctor

• Any mouth ulcer, patch or lump lasting more than three weeks; any difficulty opening the mouth. These need examining, and often a biopsyBiopsyA biopsy is the removal of a small piece of tissue so that it can be examined under a microscope. It is the test that settles what a lump, an ulcer or an abnormal patch actually is, when scans and blood tests can only suggest.Read the full definition.
• A cough that has lasted more than three weeks, a change in a long-standing cough, or any blood in what you cough up.
• Breathlessness on exertion that is new or getting worse — spirometrySpirometrySpirometry measures how much air you can breathe out and how fast, by blowing hard into a machine. It is the test that distinguishes asthma from COPD and tracks how well either is controlled.Read the full definition may be needed.
• Before starting nicotine replacement if you are pregnant, breastfeeding, or have had a recent heart attack or stroke.
• If you want a prescription medicine to help you stop, or have tried and relapsed more than once.
• If tobacco is how you manage anxiety or low mood. Treating that at the same time makes the quit far more likely to hold.
• If you have not had your blood pressureBlood pressureBlood pressure is the force of blood against the artery walls, written as two numbers in millimetres of mercury: the higher one is the pressure as the heart squeezes, the lower one the pressure as it refills. It varies through the day, so a diagnosis is never made on one reading.Read the full definition and cholesterolCholesterolCholesterol is a waxy fat the body needs to build cell walls, hormones and vitamin D. Problems come not from its presence but from the balance between the particles that deposit it in artery walls and those that carry it away.Read the full definition checked, ask for both — see our article on high blood pressure. Tobacco plus untreated blood pressure is a much larger risk than either alone.