Tobacco in its various forms, is the most common substance of abuse worldwide. Introduced in India first in the 17th century, the practice of smoking tobacco merged with the age-old habit of smoking cannabis. The traditional ‘dhumapana’ (‘drinking smoke’) came to denote smoking cigarettes rather than the chillum or hookah originally used. Tobacco in the form of cigars, cigarettes, beedis, grounded betel nut (chewable), khaini and snuff form the bulk of its usage in India. Despite adding to the country's revenue, its health hazards are well-established and despite increasing legislation over the years, the implementation of anti-tobacco measures are sadly still in their adolescence.
The World Health Organisation (WHO) estimates around 125 million smokers in India and around 72% of all males have used tobacco in any form at least once in their lifetime. The National Mental Health Survey (NMHS) conducted in 2015-16 showed 21% of the entire Indian population using tobacco with the male: female ratio being 4:1. Around 1 million deaths are attributable each year to tobacco usage, that contributes to 9.5% of the total mortality. The concerning fact is that second-hand tobacco smoke affects even more people and the young economically-productive population are among the most affected. The Indian Heart Association (IHA) in its 2015 report states that India contributes to 75% of the world’s cardiac deaths even though it consists of only 20% of the world population. Besides one of the major direct contributors of this cardiac burden is tobacco use.
Tobacco's impact: Lungs, Heart, Brain
By now there is a myriad of literature and warnings about the effects of tobacco on the lung (causing chronic obstructive lung disease, bronchitis, lung cancer), the heart (causing ischemic heart disease, angina i.e. conditions arising from decreased blood supply to the heart and consequently infarction or heart attack, hypertension i.e. increased blood pressure), and finally the brain (stroke, increases the risk of dementia i.e. a disease of the brain in which the memory, thinking and functioning of the individual gradually decline). Tobacco use in general also increases the risk of several cancers like those of pharynx, breast, colon and pancreas to name a few. The top three causes of death due to tobacco use as mentioned by the WHO Indian report 2018 are ischemic heart disease, stroke and chronic obstructive lung disease. Also, it leads to millions of premature deaths, being the leading cause of heart illness and hypertension in the young.
Though there are hundreds of illnesses that can be caused or increased by the use of tobacco, the chronic slow damage that it gradually causes is of most concern. It decreases the immunity, increases the risk of lung infections, diarrhea, muscle weakness and dementia. Thinking and processing speed, general physical ability and muscle strength slowly reduce with increasing tobacco use. As these effects are usually sub-threshold and does not manifest as frank illness till late, they are often undetected and eventually the body gets easily vulnerable to effect of other diseases. Though over the years the health concerns of tobacco have almost exclusively focused on the physical ailments, its effect on the human mind both in terms of its addicting ability and its relationship with mental disorders have largely been understated.
How Does Tobacco Affect the Mind?
Tobacco, in any form, is considered to be one of the most addictive substances available to humankind. Nicotine, the chemical constituent of tobacco, acts on the ‘reward center’ of the brain (responsible for feeling good experiences) to release a chemical called dopamine (the ‘feel happy’ substance in the body) to give a ‘kick’ which ultimately leads to the addictive habit. The psychological dependence (i.e. desperate need to take the substance of abuse) for tobacco is quite strong especially when smoked and is immediately resorted to at times of stress and anxiety. Hence, even after people have left it completely, it is easy to relapse and re-start its use. Even though it feels like causing upliftment of mood, later it leads to a chronic agitated state and the mind has difficulty concentrating and thinking without ‘tobacco’.
The more the usage, the more this effect and eventually for heavy users ‘a cigarette’ can be necessary for every single activity during the day.
Unfortunately, millions of young people succumb to its first use only on experimentation or peer pressure and subsequently get trapped in the vicious cycle of addiction. In fact, tobacco is known to be a ‘gateway substance’ i.e. an addictive product that can slowly lead to other addictions, which is quite correct. Cannabis and alcohol are the two common addictions that easily develop after the person has early and heavy tobacco use.
What is also important to know is that tobacco use leads to a chronic ‘nervous’ state in which the mind becomes easily vulnerable to disorders like anxiety and depression. Besides, smoking and use of snuff slow down thinking, cause difficulty in calculation, driving and other fine skills; increased use often leading to a constant ‘on-the-edge’ feeling, panic attacks and decreased self-confidence. ‘Tobacco’ is often looked upon as a performance-enhancer or a stress-buster which is a myth, as it just ‘hijacks’ the brain pathway for different activities leading to more dependence on the ‘smoke’ and eventually more ‘damage’. These mental effects progress subtly, and are difficult to gauge before it is already too late. Tobacco can also cause speech difficulties interfering with the voice-articulation and lead to multiple small strokes in the brain over the years of usage leading to memory, mood and urinary difficulties. The optimistic part however is that after the complete cessation of its use even in heavy users, in 60-70% of cases these effects are almost completely reversible in 5-10 years.
The Way Ahead
The Indian Government has been increasingly sensitive to the health impact of tobacco. The Cigarettes (Regulation of Production, Supply and Distribution) Act, 1975 was the first legislation to come which led to the mandatory statutory warnings on the cigarette packs. That eventually gave way to the Cigarettes and Other Tobacco Products Act (COTPA), 2003 which was extended to all forms of tobacco-containing products. However these acts mostly stay confined to the legal paper, the implementation being faulty at all levels. As a consequence, not only are the tobacco-related deaths on the rise but also the rates and complications of passive smoking. Movies, advertisement and literature further reinforce the social myths giving impetus to the tobacco use. The small inconspicuous line stating “Cigarette smoking is injurious to health” is mostly redundant and sadly neglected.
The truth is: mandating legal obligations or broadcasting compulsory advertisements depicting grotesque scenes of cancer before a movie will not make a substantial impact on the public, immaterial of their honest intentions. The awareness and understanding of the masses are of vital importance, as is the willingness to seek help devoid of stigma. The National Tobacco Control Program (NTCP) of the Central Government is the cornerstone of surveillance, policy making and also awareness and training related to tobacco use. There are established treatments for quitting tobacco which include counselling, nicotine-replacement strategies (gums, lozenges, patches, spray, etc) and medicines. They are effective and work well, provided the individual motivation and family support are in place. Tobacco cessation centres are on the rise and established in most state medical colleges. Psychiatrists and psychologists mainly deal with the de-addiction process, however the onus lies on all physicians and social-workers to help in this regard. There are training programs run by the Centre for the general practitioners and dentists to detect tobacco-related problems at the earliest and refer for the required help. The chronic users of tobacco also need regular monitoring for heart, lung and brain-related problems. The media plays an immense role to spread this message to all classes of people that “Be it any form of tobacco, its chronic use is damaging! There is help available and it works, you just have to reach out. It is difficult but not impossible. Many of the harmful effects of tobacco can be reversed after you stay away from it. It will be a long way to go, but it is always worth trying to QUIT TOBACCO!”
(Dr Debanjan Banerjee is a psychiatrist with NIMHANS, and Life Fellow, World Association of Mental Health)