Tobacco kills more people in Pakistan than every illegal drug combined, and it is the dependence least likely to be brought to a treatment centre. Cigarettes, naswar, gutka, paan and sheesha are all normal enough socially that dependence on them is rarely described as addiction at all, even by people who have tried and failed to stop many times.
Nicotine dependence responds well to treatment, and the combination of medication and structured support performs far better than willpower on its own. Islamic Medical Centre provides cessation support in Islamabad, including for patients stopping tobacco alongside treatment for another dependence.
Why stopping unaided so often fails
Most people who stop smoking do so without help, and most attempts made that way fail. That is not a comment on the character of the people attempting it. Nicotine is absorbed and reaches the brain within seconds, several hundred times a day, and each dose is paired with a specific situation — after a meal, with tea, on waking, during a break, while driving. The chemical dependence and several hundred daily habits therefore have to be dealt with together.
The other reason is that withdrawal peaks quickly and then improves, but most unaided attempts end within the first three days, which is exactly the peak. People conclude that they cannot do it when what actually happened was that they stopped at the hardest point.
What nicotine withdrawal involves
Symptoms begin within hours of the last use, peak over the first three days, and largely settle within two to four weeks. Craving is the exception and continues to appear intermittently, triggered by situation rather than by the passage of time.
- Irritability, restlessness and a noticeably short temper
- Difficulty concentrating and a sense of mental fog
- Anxiety and low mood
- Disturbed sleep, sometimes with vivid dreams
- Increased appetite and some weight gain, typically a few kilograms
- Craving lasting seconds to minutes, arriving in waves and tied to specific situations
Naswar, gutka and paan
Smokeless tobacco is often treated as the safer option, and where cardiovascular and respiratory risk are concerned it is somewhat less harmful than cigarettes. On cancer of the mouth it is not. Naswar, gutka and paan with tobacco are strongly associated with cancers of the oral cavity, and Pakistan has among the higher rates of oral cancer worldwide, largely for this reason.
The early signs are visible and easy to check: white or red patches inside the mouth, a persistent ulcer that does not heal within three weeks, a lump, or gradually reducing ability to open the mouth. Any of these warrants examination without delay. Because they are painless in the early stages, they are commonly ignored until they are not.
Sheesha and vaping
Sheesha is widely believed to be filtered and therefore mild. A single session commonly involves inhaling a far greater volume of smoke than one cigarette, along with carbon monoxide from the charcoal, and the shared mouthpiece carries its own infection risk.
Vaping is a genuinely less harmful way of taking nicotine than smoking, and it is useful for people switching away from cigarettes. It is not harmless, and for someone who has never smoked, taking it up establishes a nicotine dependence that did not previously exist. Among young people that is now the more common route in.
What treatment involves
Cessation works best when medication and behavioural support are combined; each roughly doubles the chance of success and together they do better still. Which medication is appropriate depends on the pattern of use, other medicines being taken, and any psychiatric history, so it is decided at assessment.
- Assessment of how much is used, how soon after waking, and previous attempts
- Nicotine replacement where appropriate, often a patch combined with a faster-acting form for cravings
- Non-nicotine medication where indicated, chosen with regard to psychiatric history
- A quit date, with the situations most tied to use identified and planned for in advance
- Oral examination for anyone using naswar, gutka or paan
- Follow-up through the first weeks, when relapse risk is concentrated
Stopping tobacco alongside other treatment
Almost everyone admitted for drug or alcohol treatment also smokes, and it used to be assumed that asking them to stop at the same time was too much. The evidence now points the other way: patients who address tobacco during treatment for another dependence tend to do at least as well in that treatment, not worse.
It is offered rather than imposed. For a patient in the acute phase of heroin or ice withdrawal there are more urgent priorities, and the appropriate point is usually once the acute phase has passed.
Frequently Asked Questions
- How long does nicotine withdrawal last?
- Symptoms begin within hours, peak over the first three days, and mostly settle within two to four weeks. Cravings continue to appear intermittently for longer, triggered by particular situations rather than by time since the last use.
- Is naswar safer than cigarettes?
- For heart and lung disease it carries somewhat lower risk. For cancer of the mouth it does not, and it is strongly associated with oral cancer. Anyone using naswar, gutka or paan should have their mouth examined, particularly if there is a patch, lump or ulcer that has not healed within three weeks.
- Is sheesha less harmful than smoking?
- No. A single session typically involves inhaling considerably more smoke than one cigarette, along with carbon monoxide from the charcoal. The belief that the water filters out the harmful content is not correct.
- Is vaping a safe way to quit?
- It is substantially less harmful than continuing to smoke and can help people switch away from cigarettes. It is not harmless, and for someone who has never smoked it creates a nicotine dependence that did not exist before.
- Will I gain weight if I stop?
- Most people gain a few kilograms, largely because appetite increases and nicotine slightly raises metabolic rate. It is modest against the health benefit of stopping, and it can be planned for rather than discovered.
- What medication helps?
- Nicotine replacement, commonly a patch combined with a faster-acting form for cravings, and non-nicotine medication where indicated. Choice depends on the pattern of use, other medicines and psychiatric history, so it is decided at assessment.
- Should I stop smoking while being treated for another addiction?
- It can be done and patients who do tend to fare at least as well in their main treatment. It is offered rather than required, and the usual point to begin is once the acute phase of the other withdrawal has passed.
- I have stopped many times and always started again. Is it worth trying?
- Yes. Most people who eventually stop for good made several attempts first, and each one is information rather than failure. Attempts using medication and structured support succeed considerably more often than unaided attempts.