Just like with caffeine, one develops dependency because your body gets used to the nicotine compound and quitting cold turkey may be more difficult than what non-smokers might think due to withdrawal symptoms.
AFTER half a century of studies, the science behind why it’s so difficult to quit smoking is crystal clear: Nicotine is addictive – reportedly as addictive as cocaine or heroin in some medical literature.
Any adult smoker would have heard from a family, friend, or even medical practitioner to quit or switch to less harmful products if possible.
“To reduce the risk of lung cancer you’ve got to understand the nature, production and source of the carcinogens,” said Dr Peter Harper during a media edugagement event in Kuala Lumpur on May 31 about modified-risk products. Dr Harper is a medical oncologist and one of the four founding partners of the London Oncology Clinic.
“For years, we thought that it was nicotine that caused lung cancer but it isn’t. It’s smoke – and smoke is due to combustion,” he emphasised, adding that smoking was the main contributor of risk factors for both men and women who have lung cancer.
Numbers vs rates
If you’ve ever heard discussions on tobacco control, you would have definitely come across terms like “prevalence” and “incidence”.
Prevalence looks at the number of people in a population who have a disease or outcome at one point in time (what happens to 33 million Malaysians) whereas incidence refers to the number of people in a population who develop a disease over a period of time (what doctors see in the clinic).
“If we look at worldwide prevalence of smoking at national levels, the numbers have decreased from 43% of the world population down to 26%, so it looks like success.
“However, when you look at what’s happening in clinics, what you see is that there hasn’t been a steep decline. There has been a decline but there are still roughly 1 billion smokers left in the world,” said Dr Harper, predicting some 64 million projected lung cancer deaths with this number.
This means that policymakers and healthcare professionals can’t only depend on one set of data. These measures work in tandem in helping us understand and plan for the impacts of a disease in our communities.
Looking back at Malaysia’s tobacco control policies, we’ve seen the government join as a signatory to the World Health Organisation Framework Convention on Tobacco Control (WHO FCTC) from as far back as 2003.
We then created new health and warning labels, raised the minimum cigarette price through taxes, expanded the definition of “cigarettes” and now we have the smoking ban that was introduced fairly recently in 2018 – all for the sake of lifting the cost of noncommunicable diseases (NCDs), what we call the disease burden.
But have we actually treated smoking as a health crisis or a moral one? There’s a difference in addressing the issue holistically and pragmatically versus an emotionally-charged policy that sounds good but is difficult to implement in practice.
Understanding human behaviourThe concept of harm reduction is a more realistic and humane approach when it comes to keeping people alive.
According to our National Health and Morbidity Survey (NHMS) 2019, the national prevalence of smoking sits at 21.3% which still equates to roughly seven million active adult smokers.
This year, the NHMS Adolescent Health Survey 2022 involving secondary school students aged 13 to 17 years saw a decrease in cigarette use, with an increase in e-cigarettes and vape amongst Malaysian teens.
Cigarette use decreased substantially among adolescents, with national prevalence levels dropping from 13.8% to 6.2% between 2017 and 2022. Meanwhile, alternatives like e-cigarettes and vaping saw an increase from 9.8% to 14.9% between 2017 and 2022.
Nicotine like any other drug should be treated accordingly to help wean the patient off it. But millions of smokers are still stigmatised.
“Why can’t you just quit?”This is a line of questioning that forgoes the interaction between the human brain and nicotine.
According to Dr Harper, just like caffeine, nicotine releases dopamine when ingested and is addictive. To a non-smoker, it’s hard to imagine why smokers do what they do.
Yet, a person with a caffeine addiction will also experience similar withdrawal symptoms should they suddenly quit cold turkey, but not be judged as harshly for drinking their fourth cup of coffee for the day.
It’s a matter of perception. But a negative perception has real consequences.
This stigma not only prevents smokers from seeking professional help, but also paints a one-sided policy picture where punitive and prohibitive laws punish the already vulnerable groups and leave the current smoking population with no alternatives.
This means that in spite of a “smoking ban” the healthcare burden of smoking isn’t fully resolved and will manifest 20 years down the line because there is no framework in place to help smokers quit or transition to less harmful products like snus, heated tobacco or e-cigarrettes.
Harm reduction works
But we’ve seen harm reduction methods work before in Malaysia. Our HIV harm reduction programmes have focused on people who inject drugs (PWID), one of the key populations with high HIV prevalence.
Back in 2006, the government launched two harm reduction intervention programmes: The Needle and Syringe Exchange Programme and the Methadone Maintenance Therapy.
The former was a joint effort by local non-governmental organisations and the Health Ministry to offer patients clean needles and syringes.
The latter gave heroin addicts rehabilitation therapy where heroin or other opiates were replaced with synthetic methadone at public hospitals and clinics, private practitioners, Malaysia’s National Anti-Drug Agency’s clinics and service centres and also in prisons.
The result was demonstrable. A report by the World Bank – in collaboration with Universiti Malaya and Kirby Institute, with support from our Health Ministry – found that both programmes were not only cost-effective but also cost-saving.
“It is estimated that the implementation of the two programmes resulted in a total of RM210mil saved in direct health care costs.
“This produces a return of RM1.07 for every ringgit spent over the next 10 years.
“As for effectiveness, these programmes have significantly contributed to the reduction of new HIV cases among PWID from over 4,000 per year in 2005 to only 115 in 2017.
“The HIV prevalence among PWID has also reduced from 22% in 2009 to 13.4% in 2017,” the report deduced.
Evidently, these policies successfully lowered levels of drug-related crime and reduced pressure on the healthcare and criminal justice systems.
