Anti-Tobacco Counseling

Guided by:

Dr. Girish R. Shavi

H.O.D

Public Health Dentistry

Presented by:

Dr. Preyas Joshi

2nd year Post-Graduate Student

Public Health Dentistry

CONTENTS

• Introduction

• Tobacco Use in India

• Tobacco Preparations

• Constituents in Tobacco

• Tobacco Dependence

• Benefits Of Quitting Tobacco

• Methods Of Quitting Tobacco

• Anti-Tobacco Counselling

• Pharmacotherapy

• Tobacco Cessation Centres in India

• Actions in The Community & Nation

• Conclusion

• References

The History of Tobacco

• “In ancient times, when the land was barren and the people were starving, the Great Spirit sent forth a

woman to save humanity. As she travelled over the world everywhere her right hand touched the soil,

there grew potatoes. And everywhere her left hand touched the soil, there grew corn. And in the place

where she had sat, there grew tobacco.” Huron Indian myth

• “The Spaniards upon their journey met with great multitudes of people, men and women with

firebrands in their hands and herbs to smoke after their custom.”

Christopher Columbus’ journal, 6 November 1492

• “Smoking is a custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to

the lungs, and in the black, stinking fume there of nearest resembling the horrible Stygian smoke of

the pit that is bottomless.”

James I of England A Counterblaste to Tobacco 1604

• “I say, if you can’t send money, send tobacco.”

First US President George Washington’s request to help finance the American Civil War, 1776

• Within 150 years of Columbus’s finding “strange leaves” in the New World,

tobacco was being used around the globe. Its rapid spread and widespread

acceptance characterise the addiction to the plant Nicotina tobacum. Only the mode

of delivery has changed. In the 18th century, snuff held sway; the 19th century was

the age of the cigar; the 20th century saw the rise of the manufactured cigarette,

and with it a greatly increased number of smokers. At the beginning of the 21st

century about one third of adults in the world, including increasing numbers of

women, used tobacco. Despite thousands of studies showing that tobacco in all its

forms kills its users, and smoking cigarettes kills non-users, people continue to

smoke, and deaths from tobacco use continue to increase.

Types of Tobacco Use

Marie Ng et al. JAMA. 2014:311(2):183-192

The Tobacco Atlas, World Health Organization 2002

The Tobacco Atlas, World Health Organization 2002

The Tobacco Atlas, World Health Organization 2002

Prevalence and Pattern of Tobacco Consumption in India1

• Prevalence of Tobacco Use in India: In India, the National Sample Survey Organization (NSSO)

has been conducting yearly surveys since 1950-1951. Tobacco use is part of the consumer behaviour

component of the National Sample Survey (NSS), conducted every five years. The nationwide

survey was undertaken as the 50th round of the National Sample Survey (NSS, 1993-1994) and a

total of 115,354 households located in 6951 villages and 4650 urban blocks were visited and

information on tobacco use including product types were obtained for all members aged 10 years and

above residing in each surveyed household. This information was obtained from one member of the

household, usually the male head.

• The NSSO tabulated the survey results for urban and rural resident’s gender - wise and age – wise

for 32 states and union territories. In the report the age groupings were as follows: 10-14, 15-29, 30-

44, 45-60 and 60 + years.

• The NSSO survey showed that 432,393 individuals of all ages were tobacco users. The major

findings were 51.3% males and 10.3% of females were regular tobacco users; 35.3% males and 2.6%

females were regular smokers; 24.0% males and 8.6% females were regular users of smokeless

tobacco and about 250 million users were aged 10 + years in the country.

The National Family Health Survey (NFHS)

• Another nationwide household survey, the National Family Health Survey (NFHS), in its second

round (1998-1999), collected information on tobacco use and health-related practices and behaviour

in 26 states.

• Over 90,000 households were surveyed and information on paan/tobacco chewing and tobacco

smoking were obtained for 315,597 persons aged 15 years and above.

• In the NFHS-2 report, the age categorization adopted was 15-19, 20-24, 25-29, 30-39, 40-49, 50-59

and 60 years and above.

• It was found that tobacco use among men was 46.5% and the same among women was 13.8%. The

prevalence of smoking and chewing varied widely between different states and had a strong

association with individual’s socio-cultural characteristics.

While the two surveys have similar sampling methods, it should be kept in mind that in the

National Sample Survey the male head of the household responded for all members, while

in the National Family Health Survey the female head of the household responded for all

members, which is an important difference in methodology.

THE HINDU (GUNTUR, September 24, 2013)

• India earned the distinction of being the world’s third largest producer of tobacco in 2012-13

with an estimated production of 681 million kilos, next only to China and Brazil and the second

largest exporter of FCV tobacco with Brazil leading the table.

• Flue Cured Virginia (FCV) tobacco, which is the main exportable variety produced in Andhra

Pradesh and Karnataka, accounted for about 263.55 million kilos of the total tobacco production.

• India makes a significant contribution to the national economy by earning about US$ 914.43

million foreign exchange (2012-13) besides accruing US$ 3.65 billion (2012-13) to the exchequer

by way of excise levies on manufactured tobacco.

• The tobacco industry is providing employment to nearly 38 million people, who are engaged in

the various processes of tobacco cultivation, curing, grading, manufacturing and marketing.

• Nearly 76,100 metric tons (mt) of unmanufactured tobacco is exported to Western Europe

between April 2012 and March 2013 followed by about 47,350 mt to South & Southeast Asia and

nearly 30,710 mt to East Europe. The grand total quantity of unmanufactured tobacco exports

stood at 228,025 mt.

Patterns of Tobacco Consumption in India

• There has also been a complex interplay of sociocultural factors which influenced not only the

acceptance or rejection of tobacco by sections of society but also determined the patterns of use.

• In traditional Indian joint families smoking at home was initially a taboo. It was restricted to only

the dominant male members of the family. The younger members of the family would desist from

using it in the presence of the elders and even the master of the house would not use it when an

elderly relative, especially an aged parent, was around.

• The increasing replacement of the joint family by nuclear families, especially in the urban setting,

has provided a more permissive atmosphere to use tobacco at home.2

• Although smoking tobacco was a taboo in traditional families but smokeless forms of tobacco was

widely accepted.

• Inclusion of tobacco as one of the ingredients of paan highlights the importance of this product

and wide social acceptability of tobacco chewing in ancient India.

• The social acceptance and importance of paan increased further during the mughal era and paan

chewing became a widely prevalent form of smokeless tobacco use in India. Women ate paan for

cosmetic reasons as chewing it produced a bright red juice that coloured their mouth and lips.3

Smoked tobacco in India

• Beedis: Crushed and dried tobacco is wrapped in tendu leaves and rolled into a beedi.

Beedis are smaller in size than the regular company-made cigarettes so more beedis are smoked to

achieve the desired feeling caused by nicotine. Beedi smokers are at least at an equal risk of

developing cancers as cigarette smokers due to use of smoked tobacco. Beedi making is a source

of livelihood for many families. In some families, everyone – including children – helps make

beedis. The frequent inhalation of tobacco flakes has similar effects as the actual use of the

tobacco product. Therefore, these families have an increased risk of lung diseases and cancers of

the digestive tract. And, addiction is common among these families.

• Cigarettes and cigars: A cigar is a roll of tobacco wrapped in leaf tobacco, and a cigarette is a

roll of tobacco wrapped in paper. Cigarettes may come with filters, as thins, low-tar, menthol,

and flavored – to entice more users, including women and youth and also to suggest the cigarettes

have a lower health risk, which they do not. Many people view cigar smoking as less dangerous

than cigarette smoking. Yet one large cigar can contain as much tobacco as an entire pack of

cigarettes. Cigarette smoking is more common in the urban areas of India, and cigar use is seen in

the big cities. Cigarette smoking in on the rise and is now also seen among teenage girls and

young women.

While cigarette smoking among Indian men has fallen from 33.8 per cent in 1980 to 23 per cent in 2012, it has risen from three per cent to 3.2 per cent among Indian women within the same time frame. (THE TIMES OF INDIA  May 30, 2014 )

In absolute terms, the number of female smokers in India has more than doubled, from about 5.3 million to 12.2 million in that time frame.

• Chillum: This involves smoking tobacco in a clay pipe. Chillum smoking increases chances

of oral cancer and lung cancer. A chillum is shared by a group of individuals, so in addition to

increasing their risk of cancer, people who share a chillum increase their chances of spreading

colds, flu, and other lung illnesses. A chillum is also used for smoking narcotics like opium.

• Hookah: Hookah smoking involves a device that heats the tobacco and passes it through

water before it is inhaled. It is not a safer way to use tobacco. The use of hookah was once

on the decline, but it has increased in recent years. Hookah is thought to be a sign of royalty

and prestige and is available in highpriced coffee shops in flavors like apple, strawberry, and

chocolate. It is marketed as a "safe" recreational activity, but it is not safe and is finding

increasing use among college students of both sexes. Use of tobacco in this form can result in

tobacco addiction.

• Chutta smoking and reverse chutta smoking: Chuttas are coarse tobacco cigars that are smoked

in the coastal areas of India. Reverse chutta smoking involves keeping the burning end of the

chutta in the mouth and inhaling it. This practice increases the chance of oral cancer.

Palatal lesion associated with reverse smoking

Smokeless tobacco use

• Smokeless tobacco is very common in India. Tobacco or tobacco-containing products are chewed

or sucked as a quid, or applied to gums, or inhaled.

• Khaini: This is one of the most common methods of chewing tobacco. Dried tobacco leaves are

crushed and mixed with slaked lime and chewed as a quid. The practice of keeping the quid in the

mouth between the cheeks and gums causes most of the cancers of the gums – the commonest

mouth cancer in India.

• Gutkha: This is rapidly becoming the most popular form of chewed tobacco in India. It is very

popular among teenagers and children because it is available in small packets (convenient for a

single use), uses flavoring agents and scents, and is inexpensive (as low as Re 1/- equivalent to 2

cents). Gutkha consists of areca nut (betel nut) pieces coated with powdered tobacco, flavoring

agents, and other “secret” ingredients that increase the addiction potential. Gutkha use is

responsible for increased cases of oral cancers and other disorders of the mouth and teeth in young

adults.

• Paan with tobacco: The main ingredients of paan are the betel leaf, areca nut (supari), slaked

lime (chuna), and catechu (katha). Sweets and other condiments can also be added. The varieties

of paan are named for the different strengths of tobacco in it. Some people think that chewing

paan without tobacco is harmless, but this is not true. The International Agency for Research on

Cancer (IARC) has established that people who chew both the betel leaf and the areca nut have a

higher risk of damaging their gums and having cancers of the mouth, pharynx, esophagus, and

stomach.

Khaini Paan with tobacco Gutkha

• Paan masala: Paan masala is a commercial preparation containing the areca nut, slaked lime,

catechu, and condiments, with or without powdered tobacco. It comes in attractive sachets and

tins, which are easy to carry and store. The tobacco powder and areca nut are responsible for oral

cancers in those who use these products a lot.

• Mawa: This is a combination of areca nut pieces, scented tobacco, and slaked lime that is mixed

on the spot and chewed as a quid. The popularity of mawa and its ability to cause cancer matches

that of gutkha. Its use is rising among teenagers and young adults in India.

• Mishri, gudakhu and toothpastes: These preparations are popular because people believe –

incorrectly – that tobacco in the product is a germicidal chemical that helps in cleaning teeth.

Mishri is roasted tobacco powder that is applied as a toothpowder. Mishri users often become

addicted and start applying it as pastime. Gudakhu is a paste of tobacco and sugar molasses.

These preparations are commonly used by women and involve direct application of tobacco to the

gums, thus increasing the risk of cancer of the gums. Tobacco-containing toothpastes, which are

promoted as antibacterial pastes, are popular among children. This habit often becomes an

addiction, and the children graduate to other forms of tobacco, thus increasing their chance for

cancers.

• Dry snuff: This is a mixture of dried tobacco powder and some scented chemicals. It is inhaled

and is common in the elderly population of India. Snuff is responsible for cancers of the nose

and jaw.

Pan Masala Mawa Tobacco Mishri Tobacco

Dry Snuff Creamy Snuff – applied using toothbrush or fingers 

A Three(3) Year old girl living in Village lakhpadar, Distt. Kalahandi rubbing gudakhu powder

Chhattisgarh’s state Health Minister Amar Agrawal runs a flourishing business in gudakhu, a highly harmful tobacco product believed to be the biggest cause of oral cancer in the state, despite Chhattisgarh itself having banned manufacture, storage, distribution and sale of “tobacco and nicotine-containing gutkha and pan masala”.

A mix of tobacco and decomposed gud (jaggery), gudakhu is widely consumed across rural Chhattisgarh

• A wide variety of tobaccos are grown in 16 states in India under diverse agroclimatic conditions.

• However, most of the varieties grown are of non-cigarette types. These include natu, bidi, chewing, hooka (hookah), cigar and cheroot tobaccos and account for about 77 percent of the total output.

• Cultivation of FCV tobacco was initially confined to the traditional black soil areas of Andhra Pradesh. However, to suit the quality requirements in internal and export markets, cultivation of FCV was encouraged in light soils in Karnataka and Andhra Pradesh.

• In the initial years, the varieties grown were limited to Havana tobacco used in cigars, and Lanka tobacco used in the manufacture of snuff and bidis. Subsequently, other forms, like FCV, were introduced.4

CONSTITUENTS IN TOBACCO5

• Polycyclic aromatic hydrocarbon- causes carcinogenesis

• Nicotine- potential carcinogenic agent

• Phenol- produces ganglionic stimulation & depression & tumour promotion

• Benzopyrene- plays an important role in tumour promotion & irritation

• Carbon monoxide- produces impaired oxygen transport & repair

• Formaldehyde & oxides of nitrogen- toxicity to cilia & irritation

• Nitrosamine- potential carcinogenic agent

Ill Effects Of Tobacco6,7

• Tobacco is a major contributor to oral disease.

• Tobacco use slows wound healing after dental surgery, promotes periodontal disease, halitosis

and oral infections.

• When tobacco use is combined with the intake of areca nut or alcohol, health risks due to

tobacco increase.

• Smoking causes cancer of the oral cavity and tongue, larynx and pharynx, oesophagus,

stomach, uterine cervix and lung.16 Many cases of lung cancer in India are due to smoking.

• Smokeless tobacco is known to cause oral cancer. There is some evidence that it causes some

other cancers as well. Chewing of paan (with supari) with or without tobacco is a major cause

of oral and oesophageal cancers in India.

• Smoking is a known cause of cardiovascular disease. Emerging evidence points to smokeless

tobacco use also as a cause of cardiovascular disease.

• Smoking causes most cases of chronic obstructive lung disease – emphysema and chronic

bronchitis.

• Exposure of non-smokers to second-hand smoke is an important cause of respiratory

infections, worsening of asthma and poor lung function. Many of the sufferers are women and

children.

• Newer research findings indicate that smoking is a major risk factor for tuberculosis in India.

Tuberculosis is about 3 times more common among ever-smokers than among never-smokers

and mortality due to this disease is 3–4 times greater among smokers than non-smokers.

• Pregnant women exposed to passive smoke may deliver lower weight babies. Evidence is

accumulating that pregnant women who use smokeless tobacco are more likely to have low

birth weight or stillborn babies. The birth of a baby with congenital cleft lip or palate can be a

consequence of cigarette smoking.

• Additionally, there are often long-term effects on surviving children born of mothers who

smoke or are passively exposed to smoke.

• Men who smoke or use smokeless tobacco may develop reduced fertility and sexual

impotence.

Health Benefits of Smoking Cessation8

There are immediate and long-term health benefits of quitting for all smokers

Time Since Quitting Beneficial health changes that take place

Within 20 minutes Your heart rate and blood pressure drop.

12 hours The carbon monoxide level in your blood drops to normal.

2-12 weeks Your circulation improves and your lung function increases.

1-9 months Coughing and shortness of breath decrease.

1 year Your risk of coronary heart disease is about half that of a smoker.

5 years Your stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting.

10 years Your risk of lung cancer falls to about half that of a smoker and your risk of cancer of the mouth, throat, esophagus, bladder, cervix, and

pancreas decreases.

15 years The risk of coronary heart disease is that of a nonsmoker's.

Time of quitting smoking Benefits in comparison with those who continue

At about 30 Gain almost 10 years of life expectancy

At about 40 Gain 9 years of life expectancy

At about 50 Gain 6 years of life expectancy

At about 60 Gain 3 years of life expectancy

After the onset of life-threatening disease Rapid benefit, people who quit smoking after

having a heart attack reduce their chances of

having another heart attack by 50%.

Impact Of Government Policies On Production Of Tobacco9

• Even though tobacco comes under state jurisdiction, the Government of India plays an important

role in the growth and development of the tobacco industry.

• In fact, at least six ministries of the Union Government – Agriculture, Commerce, Finance,

Industry, Labour, and Rural Development – deal with one or another specified aspects of the

industry.

• Following the increasing health concern about tobacco consumption, the central Ministry of

Agriculture has not launched any development scheme for the crop since the completion of the

Seventh Five-Year Plan (1985–90).

• However, in general, government policy has been to promote production, improve quality and

ensure remunerative prices for growers.

Government interventions in support of the industry can broadly be classified into:

(i) Institutional and regulatory support;

(ii) Price and market support;

(iii) Export promotion;

(iv) Research and development (R&D); and

(v) Direct fertilizer and credit subsidies.

• The Tobacco Board has the responsibility for regulating production, marketing and exports of

FCV tobacco grown in the states of Andhra Pradesh, Karnataka and Mahaarshtra.

• The Directorate of Tobacco Development handles marketing of non-FCV tobacco.

• Field studies carried out by the National Council of Applied Economic Research (NCAER,

1994) and by Centre for Multidisciplinary Development Research (CMDR) showed a number

of major socio-economic factors encouraging tobacco growing:

1. Richer farmers tend to prefer tobacco to other crops. Small-scale farmers take to tobacco

cultivation as something inevitable in the absence of a suitable alternative.

2. Tobacco as a crop gives superior net economic returns compared with alternative crops.

3. Tobacco is preferred due to its drought resistance and suitability for growing under rainfed

conditions. Due to tobacco’s soil preferences, cultivation is concentrated in certain states, and even

within major tobacco growing states, the crop is grown in specific districts.

4. A widespread belief prevails among farmers, especially in bidi growing areas, that no other crops

should be grown in the same land where tobacco is cultivated, as it will lower the quality of the

subsequent crops. However, this is contrary to scientific recommendation that tobacco should be

grown alternate years.

5. The prevalent practice of growing only tobacco every year is reinforced by bidi manufacturers

through their agents, who may refuse to purchase tobacco if any other crop has been grown on the

same plot. Marketing of non-FCV tobacco has been a major problem and there have been

allegations of agents exploiting farmers.

6. A well organized marketing system for FCV tobacco through the Tobacco Board assures prompt

payment to farmers, which is not the case for many other crops.

7. Farmers are reluctant to give up tobacco cultivation because of heavy investment in irrigation

equipment and barns.

8. A change in cropping is practicable only when some assured irrigation is available. For example,

the coming online of Nagarjuna Sagar dam led to a radical change in cropping pattern – from

tobacco to sugar cane.

9. Failure of other crops raised in the past.

The Bidi Industry• Bidi is tobacco rolled in a tendu leaf and tied by a string. Tendu leaf accounts for 74 percent by

weight of bidi.

• Dark and sun-dried tobacco varieties are used in bidi production. Almost 80 percent of bidi

tobacco comes from Gujarat, and the rest comes from Karnataka.

• Bidis account for over 50 percent of total tobacco use, compared with less than 20 percent by

the cigarette segment.

• There are an estimated 290 000 growers of bidi tobacco.

• Tendu leaf is almost wholly grown on government-owned forestland, with around 62 percent of

tendu leaf being grown in Madhya Pradesh.

• Annual production of tendu leaf in 1994/95 had an estimated value of Rs 14700 million. About

2 million people are engaged in leaf collection, while another 4.4 million people are employed

directly for bidi rolling. Bidi rolling is concentrated in the states of Madhya Pradesh, Andhra

Pradesh, Tamil-Nadu, Uttar Pradesh and West Bengal. Bidis are manufactured largely in the

independent small-scale and cottage industry sector. There are a few large manufacturers of

branded bidis, which tend to be closely-held, family-run businesses. The bidi industry is

estimated to have used 268000 tonnes of tobacco in 1998/99, 54.4 percent of the total apparent

tobacco use.

Role of Women in the Bidi Industry

• There are different estimates of female involvement in bidi rolling. One source estimated that

women constitute 76% of the total employment in bidi manufacture. The All India Bidi, Cigar and

Tobacco Workers Federation pay the figure at 90% to 95%. In some regions of India, bidi making

is largely regarded as “women’s work”, with the exception of young boys. In other areas, men roll

bidies if and when other work is not available or they are unable to engage in manual labor.

• In areas where the bidi cottage industry is pervasive, some women engage in bidi rolling as a full-

time occupation and are able to roll 800–1200 bidies during an 8-12 hour day. Other women work

part-time while caring for children and attending to household duties and roll 300–500 bidies a

day. Bidi wages are generally higher than those for manual labor and in some areas, such as

southwest coastal Karnataka, the siphoning off of women into the bidi cottage industry has raised

local agricultural wages and affected cropping patterns.

• The increasing shift of bidi rolling from the factory to a home-based setting and the constant

relocation of bidi companies in search of cheap transport and labor also cause insecurity and

instability among bidi workers.

Tobacco Health Warnings & Messages on Cigarette Packages in India10

India’s health warnings policy was drafted in 2006. After 2 rounds of revisions in 2006 and 2007, a

final set of health warnings were released in 2008 and were implemented on all cigarette packages

on May 31, 2009. Two warnings were rotated on cigarette packages and a separate warning was

rotated on all smokeless tobacco products.

In 2011, India’s Ministry of Health and Family Welfare proposed an amendment to the rules which

included 4 additional pictorial warnings to be used on tobacco and bidi packages, and 4 additional

pictorial warnings for smokeless packages. Implementation of these rules began on December 1,

2011 and allowed tobacco companies to choose any one picture out of each set of 4 images for

smoking and smokeless tobacco products.

On September 27, 2012, India proposed a new round of picture warnings that were to be required

in India as of April 1, 2013, although implementation of these warnings varied. A set of 3 new

pictorial warnings were developed for smoked tobacco products, and a separate set of 3 new

warnings were developed for smokeless tobacco products. Health warnings were required to cover

40% of the front of all cigarette packages.

At present, the space covered by the warning is 40%

The government of India on Wednesday, Oct 15,2014 announced new pictorial warnings for cigarette packs and other tobacco products. According to the new guidelines, effective from April 2015, 85% of space on cigarette packs and other tobacco products in India will have to be mandatorily covered with graphic and text warnings about adverse health effects, becoming the country with the highest element of warning on packages. Of the 85% space, 60% will be devoted to pictoral warnings while 25% will be covered by textual warnings.

TEXTUAL & PICTORAL HEALTH WARNINGS PROPOSED FOR APRIL 2015

For packages containing smoking forms of tobacco products

For packages containing smokeless forms of tobacco products

The size of the specified health warning on each panel of the tobacco package shall not be less than 3.5 cm (width) × 4 cm (height), so as to ensure that the warning is legible, prominent and conspicuous.

The size of all components of the specified health warning shall be increased proportionally according to increase of the package size to ensure that the specified health warning covers eighty-five per cent (85%) of the principal display area of the package

Centre defers notification on 85 per cent pictorial health warning on tobacco products

• Tuesday, March 31, 2015. the Union government decided

to defer the implementation of a notification for

increasing the size of pictorial health warning on cigarette

packets and various other tobacco products.

• The deferment move comes in the wake of Parliamentary

Committee on Subordinate Legislations (2014-15), headed

by BJP MP Dilipkumar Mansukhhal Gandhi, who has

been examining the provisions of the Cigarettes and Other

Tobacco Products Act, 2003.

The move mandating 85 percent pictorial

health warnings on tobacco product packages

from April 1 has earned India praise from the

WHO on the opening day of the 16th World

Conference on Tobacco OR Health. “It is

beautiful that India has notified the regulation.

That is the biggest pictorial warning in the

world. Whatever assistance India needs in that

direction, we are willing to provide it to

them,” said Dr Douglas Bettcher, director,

WHO department for prevention of non-

communicable diseases. The decision was

notified in October last year and comes into

effect next month.

March 20, 2015

Do favorite movie stars influence adolescent smoking initiation?

Distefan JM et al. Am J Public Health. 2004 Aug;94(8):1296

Objective:

The study checked whether adolescents whose favorite movie stars smoke on-screen are at increased risk of

tobacco use.

Results:

The researchers found that viewing a popular movie star smoking on screen created a powerful incentive for girls

to begin smoking, but the influence was not as strong for boys.

Conclusion of the article was:

Public health efforts to reduce adolescent smoking must confront smoking in films as a tobacco marketing

strategy

The take-home message is that eliminating smoking in movies may prevent a substantial number of adolescents

from smoking.

Neha Dhupuia Kareena KapoorRaima Sen

Priyanaka Chopra Aishwarya Rai Deepika Padukone

Arjun Rampal Ajay Devgan Salman Khan

Shahrukh Khan John Abraham Akshay Kumar

METHODS OF QUITTING TOBACCO

• There are three ways that people typically use to quit tobacco-

• Cold turkey

• Nicotine fading

• Tapering off

COLD TURKEY –

• Most people try to go “cold turkey”, which means they decide to give up tobacco abruptly and totally all at once.

• Going cold turkey has been very successful- put the tobacco in the trash can on your quit date; say goodbye and be

done with it.

• The "cold turkey" approach can cause mild to severe nicotine withdrawal symptoms. Drastic reductions in tobacco

use will result in withdrawal symptoms that can include irritability, fatigue, headache, insomnia, constipation,

sweating, coughing, poor concentration, depression, increased appetite, and cravings for tobacco.

• Medication or over-the-counter aids like nicotine patches or gums help to mitigate these effects, and can therefore

double or even triple your chance of success. But when you quit cold turkey, there is nothing in your body to serve as

a buffer for withdrawal symptoms.

• Experts say chances of success depend on several factors, not just a person's willpower. The extent of your

addiction, your daily habits and routines, and the amount of support you get from friends and family can

all have a big effect.

• In a 2007 study published in Nicotine and Tobacco Research, researchers interviewed more than 8,000

adult smokers from four countries attempting to quit the cigarette habit. Participants were contacted at

three separate intervals to see how their quitting methods had worked out. The researchers then compared

success rates of smokers who were trying the cold turkey approach with those who were employing other

methods.11

• The study found that 68.5 percent of the smokers made an attempt to quit using the cold turkey method,

and of those, 22 percent succeeded after the second contact with researchers and 27 percent succeeded after

the third contact. Among people using the cut down method, in which a person smokes successively fewer

cigarettes before abstaining completely, only 12 percent and 16 percent, respectively, were successful.

NICOTINE FADING-

• Nicotine fading is for those who smoke cigarettes.

• It involves switching to a cigarette with a lower level of nicotine so the addiction to nicotine can be brought

down before quitting smoking.

• If you are smoking a high-nicotine brand, switch to a medium-nicotine brand.

• If you are smoking a medium-nicotine brand, switch to low-nicotine brand.

• If you are smoking a low-nicotine brand, just switch to different low-nicotine brand.

• If you decide to try nicotine fading, make sure you do not:

Switch from a high-nicotine brand directly to a low nicotine brand

• Don’t smoke more cigarettes than you normally do, or inhale more often or more deeply

High-Nicotine Brand Medium-Nicotine Brand Low-Nicotine Brand

Benson & HedgesCamelDunhill

MarlboroMore

Benson & Hedges LightsCamel Lights

Marlboro LightsMore Lights

Benson & Hedges Ultra Lights

• The basic mechanism of action is simple: A gradual reduction in an addictive substance allows the body to

adjust to small changes, which results in fewer and more minor withdrawal symptoms.  This is the same

principle behind nicotine replacement therapy, but instead of replacing nicotine from cigarettes with

nicotine from some other source, nicotine fading simply gradually reduces the nicotine intake from

cigarettes. 

Pros

• There are no side effects to this technique, and done properly, it significantly reduces withdrawal

symptoms.

• The technique itself is free - no product to buy or pills to take. 

• This is one off the most 'natural' of all of the techniques or products, since you're not introducing any

additional chemicals or drugs into your body.

Cons

• The primary 'con' to trying to quit smoking gradually is that it may be difficult to self-monitor  - that is,

people attempting to use nicotine fading outside of a structured program may end up just 'cutting down,'

which isn't very effective over the long term.

TAPERING OFF-

• Tapering off works in a similar way to nicotine fading, but rather than reducing the nicotine level, you

reduce the amount of nicotine you are using.

• Tapering off can be used for all types of tobacco use since you just reduce the amount (e.g., fewer

cigarettes or cigars, less chew or snuff, etc.)

• This method also helps you gradually reduce the amount of nicotine in your body, preparing you for your

quit date when you will stop using tobacco completely.

• Some people who taper off see a doctor. The doctor may prescribe either nicotine chewing gum or a patch.

Both work the same way to decrease the amount of nicotine in the person's system. With nicotine gum, the

smoker chews it whenever he/she feels the desire to smoke. Over time he/she chews fewer and fewer

pieces of gum and feels less desire for a cigarette.

• The patch releases a continuous amount of nicotine through the skin into the bloodstream. Over a period of

time, the doctor changes the patch to smaller and smaller ones. Eventually it is removed. If a smoker

continues to smoke with either the nicotine patch or chewing gum, he/she could get very sick or even die

from too much nicotine in the body.

• People who quit can expect to have headaches, dry mouth, a cough, and trouble sleeping. They may feel

nervous, irritable or in a bad mood, depressed, tired, and hungry. They need to drink a lot of water and fruit

juices, especially during the first week of quitting. They should also eat plenty of fruits and vegetables,

chew sugarless gum and toothpicks, and suck on cough drops and hard candies.

ANTI- TOBACCO COUNSELLING

• Tobacco cessation counseling is defined as information given in the form of health education to the patient

on topics related to tobacco use in any form, including cigarettes, cigars, snuff, and chewing tobacco, or on

exposure to secondhand smoke. Tobacco cessation counseling includes information on smoking cessation

and prevention of tobacco use, as well as referrals to other health professionals for smoking cessation

programs.12

• DEFINITION OF TOBACCO COUNSELLING UNDER DENTAL CODE #01320-

Under this code, tobacco cessation counselling is defined as the act of giving specific advice and practical

guidance in helping an interested, generally healthy individual to quit the use of smoke and/or smokeless

tobacco. Counselling strategies and formats, delivered either individually or in groups, can include the use

of problem identification, problem solving, stress coping skills, weight control concepts, skills

development, educational materials, self-help ideas, and relapse prevention techniques. The provision of

continuing social support, care, and encouragement by the counselor(s) is essential in the effectiveness of a

tobacco cessation program.

CDT: Code on Dental Procedures and Nomenclature

The purpose of the CDT Code is to achieve uniformity, consistency and specificity in accurately

documenting dental treatment. One use of the CDT Code is to provide for the efficient processing of

dental claims, and another is to populate an Electronic Health Record.

ROLE MODEL & TOBACCO CESSATION TRAINING-

• Among the 1499 third -year dental students surveyed in the Indian Dental Students Global Health Professional

Survey (GHPS), 2005-

97.2% thought dentists serve as role models for their patients

99.8% thought dentists have a role in giving advice about smoking cessation to patients

10.5% recieved formal training in smoking cessation approaches during dental school

99.0% thought health professionals should get specific training on cessation techniques.13

ROLE OF THE DENTIST-

• During the course of oral examination, dentist should try to correlate the effect of the patient’s tobacco use on

the oro-dental problem for which the patient is attending the clinic. They should also counsel the patient to

quit between treatments as not doing so might worsen the situation.

• Dentists should understand that they are in an advantageous position to address the issue of tobacco control

during an oral check-up, as patients would listen because they are in pain.

• Nearly half of 351 dental surgeons (48.7%) surveyed in Bangalore felt that it is the responsibility of the dentist

to persuade patients to quit tobacco and just over half (54.4%) of the respondents were ‘very willing’ to

receive formal training on tobacco cessation and other intervention strategies.14

• Unfortunately, most of the dentists are unfamiliar with counselling techniques for quitting tobacco use.

Role of dentists in the clinics:

• In the clinic, dentists have an important role in helping patients quit tobacco and, at the community and national

levels, to promote tobacco prevention and control strategies.

• See the harmful effects of tobacco on the mouth.

• Are in an ideal position to counsel patients.

• See children and youth as patients and can influence them to adopt a tobacco-free lifestyle.

• Treat women of childbearing age and can inform them of the dangers of tobacco use during pregnancy.

• Can spend more time with patients than other clinicians and use this time to counsel tobacco users to quit.

• Can reinforce messages given to patients by physicians and other caregivers about the dangers of tobacco use and

the need to quit.

• Can build their patients’ interest in discontinuing tobacco use by showing them the actual effects in the mouth.

• Have a duty to promote oral health and healthy lifestyles among their patients..

Role of Dentists at the community and national level:

• Can be role models by not using tobacco or by quitting successfully. Tobacco use by dentists is a significant

barrier to tobacco cessation counselling.

• Can speak with authority in the community about the dangers of tobacco use; for example, the need to curb

tobacco use in public and educate children about the dangers of tobacco use.

• Can be effective advocates for tobacco control in the community.14

BENEFITS OF INTERVENTIONS FOR CESSATION OF TOBACCO USE

• One message which is important for dentists is that by helping people to quit tobacco and talking on this issue, they are

not wasting their time but are rather building on their practice.

• Patients prefer attending those clinics where the doctor listens to them and advices them honestly.

• Just 5 minutes of focused talk during the examination is enough to make the patient aware and conscious of the harms of

tobacco use.

• Dentists can give brief advice to non-users of tobacco, especially adolescents, and counsel them to never take up tobacco

use.

• To users of tobacco, advice and counselling by dentists on quitting tobacco use have been shown to be effective.

• Patient unwilling to quit also need to hear about the benefits of quitting.

• A good way to manage a variety of chronic oral conditions, including tobacco use and its consequences is to work with

patient to set goals and monitor therapies.

• Dentists must recognize that every interaction on tobacco use, however brief, can lead to a significant change in the

patient’s attitude and behaviour.

• Smokers can be helped to recognize that temporary abstinence is a small success that can lead to greater success in

quitting.

A BRIEF TOBACCO INTERVENTION-

• Takes only a few minutes.

• Is practical for a busy office.

• Assesses, diagnoses, educates, works with the patient.

• Is preferred by patients.

• Must encourage the patient and not be critical.14

Counselling for tobacco cessationMeans

Counselling those who’re willing to quit

Counseling should be provided using the 5-A method (ask, advise, assess, assist, and arrange)7,14,15

• Ask about tobacco use at each appointment.

• Advise all adolescents who are smoking to stop and non-smokers to never start using it.

• Assess adolescent's willingness/ readiness to quit.

• Assist efforts to quit.

• Arrange reliable follow-up.

1. ASK

Look for oral signs of tobacco use

The dentist sees the inside of the mouth and knows if the patient is using tobacco.

Implement a system to record tobacco use status

2. ADVICE

3. ASSESSAssess the patient’s readiness to quit:

Ask every tobacco user if he/she is willing to quit at this time.

• If the patient is willing to quit (in preparation) → Assess the level of dependence

• If the patient is only thinking of quitting but not willing to quit now (in contemplation),

provide a ‘tailored’ message to increase motivation.

• If the patient is not preparing to quit → Shift to the 5 ‘R’ method

Tobacco users who are heavily

dependent on tobacco usually have a

harder time quitting than less

dependent users. In a simplified way of

assessing dependence, the clinician

poses two questions:

Assess the level of dependence

• High level of dependence: Individuals who use tobacco within 30 minutes of waking up or who

use it 25 or more times (e.g. smoke 25 or more cigarettes/beedis per day).

• Moderate level of dependence: Individuals who use tobacco more than 30 minutes after waking

up or less than 25 times per day.

• Low level of dependence: Those who neither use tobacco before 30 minutes of waking up nor use

it more than 25 times a day.

Patients highly dependent on tobacco will need longer & more frequent follow up.

Assess the risk of relapse-

An individual who has quit before, even for just 30 days, has a lower risk of relapse.

Those with a higher level of dependence usually need a more intensive intervention to help them avoid relapse.

Individuals with depression or a concurrent habit such as regular alcohol drinking may be at increased risk for

relapse.

Rigorous follow up reduces the risk of relapse – on a schedule. Such patients could be referred to a counsellor or

a tobacco use cessation facility.

4. ASSISTAssist tobacco users to make a QUIT PLAN

a) Ask the patient to -

Set a firm quit date, ideally within 2 weeks

Get support from family, friends & co-workers

Review past quit attempts, what helped, or led to relapse

Identify reasons for quitting in writing & keep a copy

Reduce tobacco use during the two weeks before quitting

Anticipate challenges, particularly during the first few weeks, including nicotine withdrawal symptoms.

Typical high-risk situations- ‘Triggers’ for tobacco use:

1. During morning toilet

2. With coffee or tea

3. After meals

4. Drinking alcohol

5. Using the telephone

6. Driving

7. Seeing others smoke

8. Tension/Anxiety

9. Before starting a task

10. After completing a task

11. Relaxing or taking a break

12. Concentrating or wanting to stay

alert

13. Studying

14. Watching TV

Remove tobacco products from home/office

Throw out all tobacco products in his/her possession.

Avoid places where tobacco is available.

Encourage other tobacco users around to quit along with him or her.

Apply faith

b) Advise the patient -

Total abstinence is essential to quitting- not a single puff or portion.

Withdrawal symptoms typically decrease considerably after 1-3 weeks of quitting

Suggest alternatives to tobacco:

Chewing aniseed (saunf) or ajwain, or eating nuts or fruits, drinking water, taking walks or exercising are

helpful during the periods of craving & can be planned as a part of the daily routine.

No supari is allowed, as it is carcinogenic & may be mentally associated with tobacco by the patient.

Recommend or provide pharmacotherapy:

For depressed patients & those who have tried to quit several times & failed, pharmacotherapy can be

especially helpful.

Provide resources on quitting:

Provide reading materials on quitting that are appropriate for the patient’s age, culture, language,

educational level & pregnancy status.

• Arrange for follow up visits

• Methods: revisits, telephone contact or assist patient to arrange an appointment with his/her physician or trained

community health worker

• Timing- set a schedule

1st follow up- within a week of quit date

2nd follow up- within one month of quit date

Further- after 3 months, 6 months, 1 year

• Actions during follow-up contact-

Congratulate the patient on success (even small ones)

Empathize with difficulties: Ask the patient how he/she can overcome the difficulties

Assess pharmacotherapy: Ask the patient about the severity of withdrawal symptoms & about any possible

side-effects of medication being taken, such as irritation of the mouth, dry mouth, confusion, abdominal pain,

back pain, bodyache, sleep disturbance, dizziness, palpitations.

Counsel for relapse:

a) If a relapse occurs, encourage a new quit attempt.

b) Tell the patient that relapse is a part of the quitting process.

c) Review the circumstances that caused the relapse.

d) Use relapse as a learning experience.

Assess the need for intensive counselling: Patient especially needing it would include those with heavy

tobacco use, alcohol use or depression.

5. ARRANGE

PHARMACOTHERAPY FOR TOBACCO CESSATION

• Why use pharmacotherapy for tobacco cessation???

On account of the addictive nature of nicotine, although many tobacco users attempt to quit only 3-5% of

them are able to quit without any help,

Pharmacotherapy has been shown to double or triple the chances of quitting.

• Barriers to the use of pharmacotherapy among clinicians-

Limited availability of pharmacotherapy

Limited knowledge of pharmacotherapy

Limited experience with using pharmacotherapy

Therapeutic nihilism (“nothing works”) regarding treatment of nicotine dependence.

Tobacco user’s hesitation to accept pharmacotherapy.

• When to recommend pharmacotherapy???

All persons with severe dependence.

Tobacco users with multiple failed self-attempts.

Tobacco users unable to abstain with brief intervention alone.

Broad approaches to pharmacotherapy

Type of treatment Rationale

Nicotine replacement therapy • Supplies the nicotine but eliminates other (harmful)

chemicals in the tobacco

• Decreases the intensity of cravings and withdrawal

symptoms, enabling people to function better while

dealing with the social and psychological aspects of

their dependence

• May provide some of the effects for which the

tobacco user used the particular tobacco product

(eg- the desired mood or immediate support to cope

with stress)

Non-nicotine treatments • Act on central brain receptors and minimize

withdrawal from nicotine when the tobacco user

suddenly stops use

NICOTINE REPLACEMENT THERAPY (NRT)

• SIX FORMS OF NRT-1. Nicotine chewing gums

2. Nicotine skin patches

3. Nicotine lozenges

4. Nicotine inhalers

5. Nicotine sublingual tablets

6. Nicotine sprays

NICOTINE CHEWING GUMS

• Commonest form

• Advantage- person can control craving more effectively

• Strength- 2mg & 4 mg

• Two flavours available in India-

Gutkha flavoured- for pan parag users

Mint flavoured- for smokers

• Dosing-

1 gum every 1-2 hrs for 1st 6 weeks

1 gum every 2-4 hrs for 3 weeks

1 gum every 4-8 hrs for 3 weeks

• Duration of treatment- 4-6 weeks

• Start weaning after 2-3 months

• Weaning usually requires only education and reassurance.

• About 10-20% of those who stop smoking with the help of nicotine gum continue to use nicotine gum for 9

months or more, but few use the gum longer than 2 years.

NICOTINE SKIN PATCHES

• Simple to use & better compliance rates

• Strength-

21mg/day, 15mg/day and 7mg/day

16 hrs worn during waking hrs or 24 hrs

• Duration of treatment- 6-12 weeks

• Not freely available in India

• Side effects-

Skin rash

Sleep disturbance

NICOTINE INHALER

• Resembles a cigarette.

• Nicotine cartridges are inserted into it & inhaled like a cigarette.

• Each cartridge----3 to 20 min session.

• Recommended dose-6-12 cartridges a day for 8-12 wks, with gradual reduction over subsequent 4 wks.

• Suitable for smokers who miss the hand-to-mouth action of smoking.

NICOTINE TABLETS AND LOZENGES

• Dissolve under the tongue

• Strength - 2 mg high dose lozenge

1 mg low dose lozenge

• Advantage-

Easy to use

Facilitate nicotine absorption

NICOTINE NASAL SPRAY

• Allows rapid nicotine absorption through the nose

• Mimics the rapid nicotine levels achieved from smoking

• May help to relieve sudden urges

• Side effects-

Irritation of the nose and throat

Coughing

Watering of the eyes

NON-NICOTINE AGENTS

BUPROPRION HYDROCHLORIDE SUSTAINED RELEASE TABLETS

• Antidepressant drug; first line therapy for treating tobacco dependence

• Doubles the odds success in quitting

• Strength- 150 mg and 300 mg

• Dosing-

Set quit date 1-2 wks after beginning bupropion t/t

Continue 150 mg b.i.d for 7-12 wks after quitting

Maintenance therapy- 150 mg b.i.d for upto 6 month

SELEGELINE HYDROCHLORIDE

Dosage- 5mg p.o. Twice daily

NORTRYPTYLINE

Tricyclic antidepressant with mostly nonadrenergic properties and little dopaminergic activity

Doubles the quit rates

CLONIDINE

Central alpha agonist

0.2 to 0.4 mg/day

VARENICILINE

Partial agonist of the nicotine receptor

ANTI-TOBACCO COUNSELLING -THOSE UNWILLING TO QUIT

THE 5 ‘R’ METHOD

• ASK/ADVISE THE PATIENT ABOUT-

RELEVANCE of quitting

RISKS of continuing tobacco

REWARDS of quitting

ROADBLOCKS of quitting

REPEAT these at every visit

1. RELEVANCE: Personal relevance is highly motivating Ask the patient why quitting is personally relevant Enlighten the patient on what he/she doesn’t know.

2. RISKS of continuing tobacco use: Acute risks- Oral wounds do not heal Periodontal disease develops Blood cholesterol increases There may be harm to pregnancy (in women) Impotence & infertility (in men) Increased level of carbon monoxide in the blood (in smokers)

ANTI-TOBACCO COUNSELLING -THOSE UNWILLING TO QUIT

Long-term risks-

Tooth loss

OSF in users of products containing areca nut (supari)

Oral & other cancers

Heart attack & stroke

Lung disease

Disability

Financial losses due to prolonged healthcare needs.

Environmental risks-

For smokers, there is an increased risk of the spouse developing lung cancer & heart disease.

Women may give birth to low birth weight children.

Children exposed to tobacco smoke are in danger of developing sudden infant death, respiratory infections,

asthma, middle ear disease.

Chewers spread germs & make a mess by spitting.

ANTI-TOBACCO COUNSELLING -THOSE UNWILLING TO QUIT

3. REWARDS of quitting:

Improved health

Improved taste of food

Improved sense of smell

Saving of money

Feeling better about self

Set as good example to children

Worry about quitting stops

Withdrawal symptoms

Fear of failure

Lack of support

Weight gain

Depression

Enjoyment of tobacco

ANTI-TOBACCO COUNSELLING -THOSE UNWILLING TO QUIT

4. ROADBLOCKS to quitting:

Fear of withdrawal symptoms

Fear of failure

Lack of support

Enjoyment of tobacco

Fear of weight gain

Depression

5. REPEAT these messages at each visit:

Repeat the motivational messages each time an unmotivated patient visis.

Tobacco users who have tried to quit previously & failed need to hear that most people make repeated

attempts before they are successful.

TOBACCO CESSATION CLINICS IN INDIA

Tata Memorial Centre Mumbai

Postgraduate Institute of Medical Education & Research Chandigarh

Institute of Human Behaviour and Allied Sciences Delhi

Pramukhswami Medical College & Shree Krishna Hospital Karamsad, GUjrat

Acharya Harihar Regional Cancer Centre Cuttack

Indira Gandhi Institute of Cardiology Patna

Chtrapati Shahuji Maharaj Meedical University Lucknow

Jawaharlal Cancer Hospital & Research Centre Bhopal

Salgaokar Medical Research Centre Chilcalim, Goa

Bhagwan Mahavir Cancer Hospital & S.M.S Hospital(Govt.) Jaipur

National Institute of Mental Health and Neuro Sciences (NIMHANS) Bangalore

Cancer Institute (WIA) Chennai

Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute Delhi

MNJ Institute of Oncology & Regional Cancer Centre Hyderabad

Dr. B. Borooah Cancer Institute Guwahati, Assam

Chittaranjan National Cancer Institute (CNCI) Kolkata

Regional Cancer Centre (RCC) Thiruvananthapuram

Regional Cancer Centre(RCC) Aizwal, Mizoram

Some of the main De-Addiction Centres functioning in Rajasthan

1. Maa Gayatri Hospital Psychiatry Department, Udaipur

2. Swami Swasthya Kendra & De-addiction, Jaipur

3. Bhagwan Mahaveer Psychiatric & De-Addiction Centre, Jaipur

4. Rajasthan Wellness Clinic, Jaipur

5. Sanjeevani Nasha Mukti Kendra, Jaipur

6. Nav Vikalp Sansthan, Jaipur

7. Nasha Mukti Kendra District Hospital, Amber, Jaipur

8. Nai Aasha Nasha Mukti Kendra, Sri Ganganagar

9. Prerna De-addiction & Rehabilitation Centre, Sri Ganganagar

10. Nav Jivan, Hanumangarh

11. U-Turn Nasha Mukti Kendra, Hanumangarh

12. Sant Nasha Mukti Center, Hanumangarh

13. Mannat Sewa Sansthan, Jodhpur

14. Asha Bhawan, Jodhpur

15. Fortis Modi Hospital Psychiatry Department, Kota

16. Mittal Hospital Psychiatry Department, Ajmer

National Tobacco Control Programme (NTCP)

Only two DTCCs are supported in each state.

In Rajasthan the two DTCCs are located at

Jaipur and Jhunjhunu Distts.

A sustainable mechanism has been put in place in

Jhunjhunu district and the district administration has

now taken ownership of declaring Jhunjhunu as

Smoke free in the coming months. Squads have been

formed at the district level, challans printed, raids are

being conducted and the same model is now being

repeated at the block level as well. 

After repeated requests to the Jaipur district and state

administration, challan books have finally been

printed on the basis of sample challan designs

provided by Rajasthan VHA and raids are expected to

begin soon, to penalize violations.

ACTION IN THE COMMUNITY AND THE NATION

• IN THE COMMUNITY -

Dentists are highly respected, trusted and influential community leaders in any society.

Their voices are heard across a vast range, economic and political arenas.

• Public education-

Dentists can display educational material on anti-tobacco themes in their clinics and hospitals, and prohibit

the use of any kind of tobacco product within 100 metres of their hospitals.

Dentist can link up with non-governmental organizations to spread health awareness about the ill-effects of

tobacco and promote cessation in schools, colleges and communities.

Dentists can sensitize youth groups to become efficient awareness generators in the community and monitor

the implementation of tobacco control laws.

• Media advocacy-

Dentists can actively engage the media in creating awareness among the masses about tobacco control

issues.

Dentists can participate in talk shows on television and radio to talk about tobacco use issues.

• AT THE STATE AND NATIONAL LEVELS -

Dentists can use their influence to encourage governments to put in place tobacco control measures.

Dentists can be involved in both direct advocacy (influencing decision- makers) and indirect advocacy

(building support among the general public to put pressure on decision-makers to initiate change).

As members of professional organizations, dentists can play an important role in tobacco control advocacy

at the state and national levels.

• Making the profession and dental facilities tobacco- free-

Dentist associations can prepare a national ‘Code of practice on tobacco control for dentists’. This code of

practice on would highlight the potential role of dentists and their organizations in the treatment of tobacco

dependence and provide guidance on organizational challenges and activities that can be undertaken to

promote a tobacco-free profession.

• Advocacy with the state and national governments-

Dental associations can advocate for the inclusion of tobacco cessation as an important component in

national health programmes such as-

o National Rural Health Mission

o National Cancer Control Programme

o Reproductive and Child Health Programme

Dentists can advocate for the levy of a ‘health tax’ on the sale of every packet of tobacco, beedi, paan

masala and cigarettes, which could be used for health education on the dangers of tobacco use.

Dentists and their associations, along with other health professionals can participate in the development of

a national plan of action for tobacco control in accordance with the Indian Tobacco Act, 2003.

All conferences and events organized by dental professionals should be declared tobacco free.

C O N C L U S I O N

• Tobacco cessation in simple words means stopping tobacco use, which is in some ways the most difficult,

as well as for many the most successful, thing the person concerned may have done.

• Only 5% of the world’s population has access to comprehensive tobacco cessation services.

• It is sad that the biggest cause of preventable death and disease has the least amount of effective

intervention available.

• As health professionals, our core responsibility is two-fold:

Play a role in reducing the use of tobacco in the community by providing clear and definite advice on

the dangers of tobacco to the public in general and to patients in particular.

Encourage tobacco cessation with proper advice, support and treatment.

Bibliography

1. Soni Preeti et al. Prevalence and Pattern of Tobacco Consumption in India. International Research Journal

of Social Sciences 2012;1(4):36-43

2. Aghi M. et al. Initiation and maintenance of tobacco use. Women and the Tobacco Epidemic: Challenges

for the 21st Century. Geneva: WHO (2001)

3. Arora M., The Tobacco Journey: Seeds of A Menace. Health for the Millions, 29, 30-46 (2003)

4. Tobacco use in India: An evil with many faces. 2009, American Cancer Society, Inc.

5. Peter S. Essentials of preventive and community dentistry.3 rd ed.New Delhi:Arya (Medi) publishing

House;2006

6. World Health Organisation. Helping your patient remain tobacco-free. Ministry of Health & Family

Welfare, Government of India;2006 May

7. National Cancer Control Programme. Manual for tobacco cessation. New Delhi: Directorate general of

Health services, Ministry Of Health and Family Welfare, Government of India; November 2005

8. World Health Organization

http://www.who.int/tobacco/quitting/en_tfi_quitting_fact_sheet.pdf Accessed: 20/07/2015

9. Issues in the global tobacco economy: Selected case studies. Food and Agriculture Organization of the

United Nations. Rome, 2003

10. Framework Convention Alliance and the International Union Against Tuberculosis and Lung Disease

http://www.tobaccolabels.ca/countries/india Accessed: 20/07/2015

11. Yooseock Cheong et al. Does How You Quit Affect Success? A Comparison Between Abrupt and Gradual

Methods Using Data from the International Tobacco Control Policy Evaluation Study. Nicotine and Tobacco

Research 2007;9(8):801-10.

12. Ahmed Jamal et al. Tobacco Use Screening and Counseling During Physician Office Visits Among Adults —

National Ambulatory Medical Care Survey and National Health Interview Survey, United States, 2005–2009

MMWR Morb Mortal Wkly Rep. 2012;61(02):38-45

13. V Costa de Silva et al. Tobacco Use and Cessation Counseling - Global Health Professionals Survey Pilot

Study, 10 Countries, 2005. Morb Mortal Wkly Rep May 27, 2005;54(20):505-09.

14. Dr. Mihir N. Shah. Reference guide: Help your patients remain tobacco-free. Ministry of Health and Family

welfare, Government of India & World Health Organization .May, 2006.

http://www.cccindia.co/corecentre/Database/Docs/DocFiles/tobacco_guthaka.pdf . Accessed :August 05, 2015.

15. Tomar SL. Dentistry's role in tobacco control. J Am Dent Assoc. 2001;132 Suppl:30S-35S.