Kripa Malla* started smoking when she was thirteen. Initially it was one cigarette a day, which gradually went up to five. Now at 23, she sometimes has as many as twenty in a day. Her yellowed teeth, persistent cough and decreased appetite are only some of the worries that irk her. The fact that she has tried to quit and failed multiple times adds to the smokers’ woes.[break]
“It’s extremely hard to quit but the health consequences are even harder to deal with. I have persistent chest pains and cough now,” says Kripa mentioning that she’s visited the hospital several times in the past three months.
“The doctors have advised me to stop smoking and I’ve tried but failed repeatedly. I won’t smoke the whole day but the cravings for one before I go to bed make me succumb to the temptation,” she says.
Similar is the story of Piyush KC, a 27 year old software engineer, who has been smoking for over ten years and has tried to quit countless times. He started smoking when he was in school and by the time he was in college, he was up to a full pack a day. He has steadily increased his smoking, reaching a peak consumption of nearly 40 cigarettes a day.
He continues to smoke almost two packs a day, despite efforts to quit. Recently married, his wife complains that the expensive habit is creating an unnecessary financial strain on their meager resources. Piyush himself no longer gets as much pleasure from smoking as before and admits that only the first cigarette of the day gives him the high he is looking for when he lights one up.
He agrees with Kripa and adds that quitting is easier said than done and that it’s best not to take up smoking in the first place.
“Once you’ve started smoking, I don’t think there’s a way out. You can try but when you see your friends smoking it doesn’t take long before you find yourself giving them company once again,” says Piyush adding that nicotine addiction is the most difficult addiction to come out of.
Nicotine in cigarette smoke affects mood and performance. It meets the criteria of a highly addictive drug besides being a potent psychoactive substance that induces euphoria, reinforces its own use and leads to nicotine withdrawal syndrome when it is absent, making it difficult to quit.
Nicotine addiction is the second leading cause of death worldwide. The important causes of smoking related mortality are vascular disease, cancer and chronic obstructive pulmonary disease (COPD). “Smokers don’t have much stamina. It’s like being old before you’re old,” says Dr Mahesh Raj Ghimire, medical officer at the Emergency Department at Sumeru Hospital in Dhapakhel.
Currently, there are 1.3 billion smokers in the world and 84% of them are in developing countries. If the current smoking trend continues, tobacco will kill 10 million people each year by 2020. According to WHO, in Nepal the prevalence rate of smoking is 56.5% in men and 19.5% in women which is high in comparison to other countries.
Research investigating why people smoke has shown that smoking behavior is multifaceted. Factors influencing initiation of smoking differ from those influencing maintenance of smoking behavior. Nicotine dependence, genetic factors, and psychosocial factors like peer pressure influence maintenance of smoking behavior.
Photo:Chandra Shekhar Karki
“The younger people are when they begin to smoke, the more likely it is that they’ll become adult smokers,” says Dr Ghimire adding that a lot of young girls take up smoking to lose weight. Since nicotine decreases appetite, the fact that it might help them lose weight is so overpowering that they don’t consider the devastating effects of smoking.
“Nicotine is both a stimulant and a depressant. It’s normal for smokers to get a high while smoking in the morning and then feel melancholy during the day and this can be extremely harmful.”
The government banned smoking in public places with the anti-smoking act last year. But the campaign did not last very long despite the police arresting offenders on and off. The immediate effects were praiseworthy but without proper policy it fizzled out in no time. The police had to step back in the face of arguments that private vehicles and roads cannot be termed public places.
The anti-smoking law also had provisions for the mandatory printing of colored pictures on cigarette packets showing the harmful effects of smoking and banning the selling of individual sticks of cigarettes but these have not been implemented.
Even if the government can’t implement policies effectively, Dr Ghimire strongly recommends that smokers consider smoking cessation because of the direct correlation between smoking and both ischemic stroke and hemorrhage. “Counseling, nicotine replacement and oral smoking cessation medications are some of the options smokers can try out if they want to quit. But these will only help coupled with strong will power,” he says.
Often associated with independence and making a fashion statement, smoking has become a trend in the recent times with young boys and girls reaching for a cigarette without giving it a second thought.
Dr Ghimire says the increase in the number of children experimenting with smoking is a matter of great concern. He says, “This is more than just trying a cigarette. The rise in those experimenting with smoking has been matched by an increase in regular smokers as well.”
“If an increase in experimentation was all that it was, it would be no problem. But some of them do go on to regular smoking and then start a habit which may go on for years. The health consequences can be grave.”
The government’s awareness campaigns to discourage smoking and the statutory warnings seem to fall on deaf ears. Despite being aware of the repercussions of long term smoking and the fact that smoking cuts at least 10 years off a person’s lifespan, the incentive to quit seems to be lacking.
But here’s the good news. According to a research by Dr Prabhat Jha published in New England Journal of Medicine people who quit smoking before they turn 40 regain almost all of those lost years.
“That’s not to say, however, that it is safe to smoke until you are 40 and then stop. Former smokers still have a greater risk of dying sooner than people who never smoked. But the risk is small compared to the huge risk for those who continue to smoke,” says Dr Jha as a part of his research findings.
Dr. Jha’s team has found that people who quit smoking between 35-44 years of age gained about nine years and those who quit between 45-54 and 55-64 gained six and four years of life respectively.
Professor Amartya Sen, the Nobel Prize winner in economics once said, “The inability to develop an appropriate public policy about smoking has been one of the bigger failures of public action in most developing countries, in contrast to strong tobacco control in most western countries.”
His statement is further validated by Dr. Jha who noted that smoking would decline much faster if their governments levied high taxes on tobacco, as seen in Canada and France. According to him, taxation is the single most effective step to get adults to quit and to prevent children from starting.
Though Tobacco Control and Regulatory Bill drafted by Ministry of Health and Population (MoHP) in 2010 has all the provisions from pictorial health warnings in cigarette packets to levying heavy taxes on cigarettes, there are no clear signs whether these laws will be implemented in the near future.
The people should also realize that laws alone cannot limit the consumption of tobacco and cigarette smoking. While it’s best to refrain from taking up smoking in the first place, if you are already hooked, try and quit. Make that effort. For your family. For yourself. And no, it’s not cool as much as you’d like to believe otherwise.
Arniko’s story
Arniko can’t point to a specific reason he started smoking. Perhaps he started in an attempt to fit in with his friends back in college, he says. In his mid-forties, Arniko suffered from a stroke which required him to be hospitalized for weeks. His four year old daughter couldn’t understand what was wrong with her father and why he wouldn’t come home.
After being discharged from the hospital, Arniko decided that he needed to stop smoking. After several unsuccessful attempts to quit in the past, Arniko has recently quit for good a few months back. His wife threw out the lighters and ashtrays and glued a picture of their daughter on the cover of his daily planner. He got advice from his doctor and used a prescription to help. He hasn’t smoked in 3 months and is determined never to do so.
Radhika’s story
It’s not easy being a single parent, and for Radhika, it’s especially challenging. She’s a student, a bank employee and the mother of a child with severe asthma.
Radhika’s daughter was 5 years old when she was diagnosed with asthma. Radhika never smoked but many of her daughter’s attacks were triggered by exposure to secondhand smoke. Radhika’s husband was a smoker. They didn’t know the connection between secondhand smoke exposure and asthma.
Binod’s Story*
Binod began experimenting with cigarettes at age 15 and by the time he turned 17, he was a regular smoker. He was only 37 when the damage to his body from smoking became evident. He noticed he was having difficulty swallowing. He went to the doctor and was diagnosed with lung cancer so advanced it was necessary to remove one of his lungs. A few years late he was diagnosed with oral cancer had to undergo surgery followed by months of chemotherapy and radiation. Now, 57 year old Binod has been smoke-free and cancer-free for over ten years.
Priya’s Story*
Priya came from a family of smokers. She started sneaking cigarettes at the age of 17. Although Priya had quit smoking when she was pregnant, she eventually started again, smoking on and off for several years.
Last year, at the age of 46, Priya suffered a stroke which the doctors linked to her many years of smoking. The stroke caused partial paralysis and she had problems with speech.
Priya doesn’t smoke anymore and has fully recovered. She doesn’t hesitate to admit that the memories of being hospitalized and not being able to move or talk were so scary that she has vowed never to touch a cigarette.
Laws for the sake of it!
Considering the high rate of tobacco consumption in Nepal, the government of Nepal had decided to ban smoking in public places in August 2012. Though the Ministry of Health and Population (MoHP) has drafted the Tobacco Control and Regulatory Bill 2010, it came into effect only after two years.
Apart from prohibition of smoking in public places, Tobacco Control and Regulatory Bill includes provisions for prohibition of smoking in public transport and workplaces, ban on all
forms of tobacco advertisement, promotion and sponsorship, pictorial health warnings in cigarette, bidi and other tobacco packets, prohibition of sale of tobacco to and by minors and pregnant women.
The ban on smoking in public places was considered a huge step towards control of rampant sales of tobacco products. In two months time from the day the ban was implemented, police arrested 3000 people for smoking in public and fined over 700 offenders who were found smoking in public places such as Bir Hospital, Singha Durbar, Thamel, Basantapur, New Road, Kamalpokhari, Thapathali and Ratnapark areas.
But soon after the issue fell out of people’s interest and attention, the smokers were seen taking long drags in public spaces. The smokers and police also argued upon the demarcation of public spaces.
Though the ban on smoking in public places was a commendable effort by the government and the police alike, implementation wasn’t the least bit effective. With repetitive problems in implementation of laws such as this, it seems that Nepalis should focus on updating their common sense rather than policies. Don’t smoke; at least in public places, it’s a no brainer!
Hard to quit?
Motivate a little more...
The message, “Smoking is injurious to health” is an old one; probably every smoker reads it at least twice a day on the very cigarette pack they own. But cigarettes are not to be taken lightly, for they contain more than 4000 chemical compounds and at least 400 toxic substances. Smoking is not only the reason for many illnesses, including various hazardous cancers but smoking also affects longevity. Non-smokers can also look forward to a healthier old age than smokers.
The Week caught up with Dr Jay Prakash Jaiswal, consultant physician and cardiologist at Norvic International Hospital, Thapathali, to talk about the health effects due to cigarette smoking.[break]
Does smoking from an early age have harmful effects than when you start later in life?
If you start smoking from an early age and continue it, then the duration will definitely affect your health. As the number of years you’ve been smoking increases, the health hazards also escalates. According to the pack year method of quantification of cigarette smoking, if a smoker has 10 pack years (Pack year = (Number of cigarettes per day/20)*years as a smoker), then his probability of getting infected by smoking related diseases increases by 70-80% than the smokers whose pack years are less than 10.
What kinds of diseases fall under smoking related diseases?
Smoking triggers the possibilities of causing various dangerous health hazards. A smoker can suffer from heart attack, lung fibrosis and all possible cancers except liver cancer.
What are some of the methods one can apply to quit smoking?
You need a lot of motivation to quit smoking. There are cases where people start young but do not continue smoking later in life as there’s a lot of pressure for young smokers to quit as they have a long life to live and cannot risk their health due to smoking.
It’s hard to quit because when people start smoking they don’t realize the potency of the addiction. Many people say that they can quit anytime but that never happens once you’re hooked to cigarettes. Alternatives like nicotine chewing gums or other medications never work if people do not have strong will power.
What do you suggest for the people who cannot quit smoking but want to keep tabs on their health?
If you are a smoker then you need to keep track of your health more than non-smokers. So, I recommend a complete whole-body check up every year to know about your overall health status. Complete cardiac checkup and pulmonary function check up are musts for smokers to avoid any sudden illness due to the side effects of smoking cigarettes.
What kind of people are at high risk of being affected from cigarette smoking?
Though smoking is harmful for everybody, people with blood pressure issues, diabetes and cholesterol are at high risk from smoking. Smoking can be dangerous for people with a history of heart ailments in the family. And of course, pregnant women should also avoid smoking cigarettes to ensure the mother and child’s health.
What about passive smoking? What are its harmful effects?
Generally, in big cities like Kathmandu, Mumbai, Shangai, it’s said that due to the increasing pollution every person is affected by smoke equivalent to 10 cigarettes a day. So, if you are a smoker, your first cigarette is actually the 11th one.
Passive smoking is a huge problem and is as dangerous as active smoking. The young patients of Chronic Obstructive Pulmonary Disease (COPD) are mostly affected due to passive smoking and generally, they have someone at home who smokes. Passive smoking is hard to keep a check on but it’s as harmful as smoking cigarettes.
What ways do you recommend for the people who want to quit smoking?
The main factor is motivation. Then, you should break the fixed pattern. Some people smoke with coffee or tea, some smoke while they are drinking; some need to smoke to go to toilet in the morning. So you should recognize the fixed pattern and try to break those habits in order to quit for good.
What do you think of the government ban on smoking in public places?
It’s a good start to curb smoking. Though, it’s clear that people will never succeed in quitting smoking unless they are really motivated to do so, the outer reinforcements can also help. If you ban smoking in public places and allocate a separate room for smokers in places like cinema halls or hospitals, then people might not smoke or the duration between cigarettes might be longer as they don’t want to be identified as smokers in public or don’t want to take the trouble to walk all the way to the smoking zone.
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