Smoking cessation remains one of mankind’s hardest challenges.
Quitting is tough – anyone who has gone through the journey can attest to this.
As American novelist Mark Twain famously joked: “Giving up smoking is easy ... I’ve done it a hundred times!”
Like him, many have repeatedly tried to give up smoking tobacco, only to return to the habit as nicotine, the chemical contained in tobacco, is reportedly as addictive as cocaine or heroin.
Cigarettes are designed to rapidly deliver nicotine to your brain.
Inside your brain, nicotine triggers the release of chemicals that make you feel good.
Over time, as you continue to smoke, nicotine changes how your brain works and makes you crave for it just to feel “normal”.
According to the World Health Organization (WHO), there are 1.3 billion smokers in the world.
Four out of every five smokers live in low- and middle-income countries, where the burden of tobacco-related illness and death is the heaviest.
In Malaysia, the prevalence of smokers aged 15 and above in 2019 was 21.3% (4.9 million people), a slight drop from the 22.8% (five million) in 2015.
Last year (2023), our government removed the generational endgame (GEG) clause from its Control of Smoking Products for Public Health Bill 2023.
The move followed an opinion issued by the Attorney-General that the proposed age-based prohibition – which sought to ban the sale of tobacco and vape products to anyone born from Jan 1, 2007, onwards – was unconstitutional because it would create two sets of laws for two different groups of citizens based on age.
Around the same time, New Zealand also scrapped its world-leading law to ban the sale of tobacco to anyone born on or after January 1, 2009.
The anti-smoking law was designed to save thousands of lives and prevent new generations of young adults from smoking.
The country was on track to becoming smoke-free by 2025 when the government made a U-turn to help pay for tax cuts, infuriating public health officials and anti-tobacco groups.
Redoubling efforts
While these moves are a win for the tobacco industry, it just means that we need to continue to increase our efforts to get people to quit smoking.
“So, even if policies are in place, there is no access to the journey to quit smoking or the support is patchy,” says University of Auckland in New Zealand’s National Institute for Health Innovation director Professor Dr Christopher Bullen.
“It is a challenge to widen accessibility, but digital reach can help as mobile phones are well distributed, even in remote populations.”
In Malaysia, the mQuit service has been available since 2015 through public-private partnership, with the objective of making smoking cessation services accessible throughout the public and private sectors.
The services were further enhanced with the Tobacco Quitline counselling system and a website to promote and facilitate registration of smokers via www.jomquit.moh.gov.my.
“If we think of smoking as a chronic relapsing condition, there are effective treatments out there, but not all are guaranteed to be successful.
“We’ve got to find what works for people,” says Prof Bullen.
The Society for Research on Nicotine and Tobacco president was in town recently to attend the first Asean Advisory Board on Smoking Cessation (AABSC) – a network of leading experts coming together to combat tobacco and nicotine addiction.
Hosted by consumer health company Kenvue, the board acts as a forum for capacity building and knowledge transfer among experts in smoking cessation.
Replacing nicotine
Among the clinically-proven treatments that can double the chances of successfully quitting smoking is nicotine replacement therapy (NRT).
NRT comes in various forms, including chewing gum, transdermal patches, tablets, lozenges and mouth sprays.
The products contain and release a low level of nicotine, without the tar, carbon monoxide and other poisonous chemicals present in tobacco smoke.
It can help reduce unpleasant withdrawal effects, such as bad moods and cravings, which may occur when you stop smoking.
The mouth spray, which was launched here last year, is the fastest craving relief available – two consecutive sprays works to relieve cravings in as quickly as 30 seconds.
Says Prof Bullen: “Electronic cigarettes (vapes) are also effective, but because it is not a pharmaceutical-grade product, its contents are not regulated like nicotine patches or gum.
“So there is a question mark over the safety of long term use.
“But as far as evidence that combines all clinical data goes, both NRT and ecigarettes are probably equally effective as treatment.
“Certain depression medications and behavioural therapy also seem to work on some people.”
In Malaysia, vapes are not one of the aid devices used to quit smoking, although it is listed as being under research review in the latest Clinical Practice Guidelines on Treatment of Tobacco Use Disorder published in 2016.
“Despite so many vaping products out there, none of the manufacturers want to come forward to do any testing on treatment methods, so no healthcare professional is going to recommend using ecigarettes as a smoking cessation tool.
“People have been abusing these products for a long time because there is no regulation on safety (yet),” says Universiti Malaya consultant psychiatrist and addiction medicine specialist Associate Prof Dr Amer Siddiq Amer Nordin, who also sits on the AABSC.
According to him, most smokers will need seven to nine attempts before they stop puffing forever.
“Just because they failed once doesn’t mean they won’t be successful the next time.
“It’s similar to monitoring your blood pressure or sugar levels – you’re not going to get it right all the time.
“It’s also important to note that any period is the best time to quit – there will still be a benefit for you in quitting as it improves your health and wealth,” he says.
Prof Bullen adds: “We urge them to have another go if one method doesn’t work – use the disease management approach.”
Providing support
Most addicts smoke around 20 cigarettes a day, with the severely addicted going up to 60 sticks daily.
Assoc Prof Amer says: “For the smoker who is already addicted – particularly if he started at an early stage due to peer pressure – it’s not really his fault.
“If he suddenly stops, he will get physical and psychological withdrawal symptoms in the short and long run.
“For individuals who want to quit, the first week is the vital week – that’s when we really need to support them.
“If they can get through the first week, they are often able to get through the first month, then the first 100 days, then one year.”
If NRTs are not available, then the focus is on counselling for the first two weeks, although the counsellor has to be properly trained to ask the right questions.
Prof Bullen says: “Basically if you’re using aids, all these withdrawal symptoms such as irritability and insomnia, are highly manageable.
“Quit smoking programmes are such that we’re looking at tapering off the aids eventually, and the majority of them can do this in six to eight weeks.”
For those who don’t want to register in mQuit, NRTs can also be purchased over-the-counter at pharmacies or are obtainable by prescription from a doctor.
One patch or one gum a day is equal to half a pack of cigarettes.
The current protocol is to use them for three months before you wean yourself off.
Is quitting cigarettes easier than quitting alcohol?
Based on our population demographics, Assoc Prof Amer says no.
“The number of people who smoke are far more than those who drink, and since the price of alcohol is much higher than cigarettes, it’s easier to stop drinking.
“Plus it’s fairly acceptable to smoke.”
However, he does note that it is more difficult to find a medical specialist to help with alcohol abuse, whereas quit smoking clinics are readily available around the country.
“We’re still hoping for a smoke-free Malaysia by 2040.
“It’s challenging, but having a goal allows us to aim for treatment, or else we’ll be faffing about,” he says.
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