SMOKING is not a habit. It’s an addiction, and like all addictions, you would need help to recover from it.
Unlike years ago when you might have to go it alone, today there are quit clinics around the country and even medication to help you stop smoking.
Dr Amer Siddiq Amer Nordin, psychiatrist and smoking cessation specialist with Universiti Malaya Specialist Centre, says that whether you are young or old, the addiction is the same.
“The treatment is the same and the health consequences of quitting are pretty much the same. The only difference is that the elderly might have some difficulties with picking the choice of treatment because they might have co-morbidities and health consequences,” says Dr Amer.
However, he does note that the longer the duration of smoking, the higher the dependence towards nicotine, and the more challenging it is to quit. But, the success rate of quitting is the same between the young and the old.
Associate Prof Dr Farizah Mohd Hairi, Department of Social and Preventive Medicine, Faculty of Medicine at Universiti Malaya, reveals that the elderly may have tried quitting many times and they may feel a bit defeated.
“Perhaps the support that they get is not that great. We need to help them by using pharmacotherapy and behaviour therapy, because we know from the evidence that the combination of therapies helps them to quit and is better than by just motivating them.
“A lot of people do want to quit, but they don’t know where to find the help. According to the global adult tobacco survey, most people want to quit. I think the studies showed about 70% want to quit,” says Prof Dr Farizah.
She informs that there is no documented data for success rates in the elderly Malaysians.
Motivation to quit
According to Dr Amer, these are the motivating factors for the elderly to quit:
Health problems – The most common is heart disease, especially for male patients. After menopause, the female patients’ risk of heart disease is equal to the male patients.
Breathing difficulty – While this may prompt the elderly to give up smoking, unfortunately sometimes the damage is already done.
“For example, chronic obstructive pulmonary disease (COPD) or chronic obstructive lung disease. In such cases, the damage is already done and there’s not much we can do even if you quit smoking. However, quitting will stop that particular disease from progressing further,” says Dr Amer.
Cancer – Smoking is one of the main preventable and major risk factors for developing cancer and having a recurrence.
Price of cigarettes – Dr Amer says that normally the elderly who smoke might smoke 30-40 cigarettes per day. With the current price of RM13.50 for a 20-stick pack, that would be almost RM30 per day. “Sometimes, when you’re not earning an income, trying to get that level of money to buy cigarettes might be quite a strong deterring factor,” he adds.
Family – In urban areas where awareness of health issues is higher, the grandchildren might influence the elderly to give up smoking.
Make a date
Dr Amer says that the first thing you need to do is set a quit date. Once you have decided to quit smoking, you need ot set a date and it needs to be within two weeks of making the decision.
The cigarette has often been described as a smoker’s best friend – it’s there during hard times and bad days. For the elderly whose children are not living with them and whose spouse has died, the cigarette may often be their only friend.
“So, sometimes letting it go can be quite a big thing. In clinical trials we have found that that last cigarette is the hardest for them to let go. They just feel that sense of attachment,” says Dr Amer.
How should you go about quitting?
Everyone knows of at least one person who quit cold turkey. But, can it be done?
Dr Amer does not recommend it. According to him, the current evidence is still against going cold turkey.
“I know a lot of people will say that their grandfather quit on his own, their mum quit on her own or they were able to quit on their own, but research shows that those who quit unaided, cold turkey, have a success rate of between 2% and 4%.
“That means out of 100 people who quit, only four of them will be successful. These studies were often done cross-sectionally, so they were done in one period of time. At the time when an individual says that he quit, we are unsure of how many attempts he had before he managed to stay quit.
“Other studies have shown that for one individual to quit, normally there would be seven or eight attempts. So, it’s quite misleading to know whether or not going cold turkey is the way to go.
“What we do know is that because of the withdrawal symptoms that individuals have with quitting smoking, it is one of the most addictive drugs with quite immediate withdrawal symptoms. They tend to feel uncomfortable, some report feeling irritable, some may get depressed, and then you’ve got a little bit of the longer consequences – they might gain a little bit of weight. These are more pronounced when you quit cold turkey, compared with when you quit with aid,” explains Dr Amer.
What sort of aid?
You don’t have to go it alone. There are various types of aids and services and professionals to help you quit smoking.
Quitting an addiction is hard and if the quit attempt comes with bad withdrawal symptoms, this becomes an additional deterrent for those wanting to quit.
According to Dr Amer, aid like medication reduces the withdrawal symptoms quite dramatically, so quitting is not as uncomfortable.
“With aid, often it is reported that twice as many people are able to quit as those doing it without aid, the quit attempts are much more comfortable, and therefore, if they were unsuccessful the first time around, they would be more likely to consider quitting a second time around,” says Dr Amer.
Types of aid:
Medication – Dr Amer says that medication like Varenicline can be taken while you are still smoking.
“What the medication does is it cuts off that feeling of euphoria – that’s how the medication works. You yourself will feel that smoking is no longer pleasurable and more often than not the smoker himself or herself will decide that there’s no point continuing because there’s no effect from it.
“This medication allows them to not have withdrawal symptoms and at the same time not experience any positive effects of smoking. So, they are able to make a conscious decision to not continue smoking,” he adds.
NRTs (nicotine replacement therapies such as the nicotine patch, gum and lozenges) – The nicotine from the cigarette is replaced with the NRTs, which in a few months will also be tapered off.
“Why do we keep them on NRT? Because we know that if someone quits cold turkey, they will get withdrawal symptoms. So the NRT reduces the amount of nicotine in a controlled fashion because the medication is dispersed into the system in a controlled fashion.
“So, we are able to calculate how much of treatment is given and then taper down the treatment, which physiologically reduce the receptors in the brain that want the nicotine. So, quitting will be smooth for these individuals,” says Dr Amer.
Quit clinics – There are 450 quit clinics in Malaysia, including 30 in Sabah alone. Those wanting to quit should consider visiting one of these clinics. Being a government initiative, it is of medium cost, and the clinics are easily available across the country.
(A full list of quit clinics can be found at http://www.infosihat.gov.my/infosihat/klinikberhentimerokok.php)
These clinics offer treatment and support in terms of counselling. Often you would have to go for a few visits where some level of brief intervention and minimal counselling is provided.
“The evidence shows that the result is definitely much better for those with counselling plus aid. It’s also on a case by case basis. Some patients might not be very comfortable with certain treatments because of past experience.
“Referring to big services like Universiti Malaya Medical Centre where you have sub-specialists might not be a possibility for some of these patients because they are not in KL,” says Dr Amer, explaining that some individuals go through intensive counselling – 30 minutes or more, to assist them through withdrawal.
Hospital assistance – Dr Amer informs that most hospitals also have quit smoking services within the family medical specialists.
“This is quite useful because the older people normally have other health problems, and this way they can be seen by the family medical specialists and treated for their medical complications,” he says.
Family support is also very important.
Normally during clinical sessions, the person wanting to give up smoking would be seen with his or her family, if they are willing, and they are advised on how to offer support.
How about the e-cigarette?
In the past five years, we’ve seen more people using the e-cigarette, or electronic nicotine delivery devices.
Dr Amer informs that the consensus by WHO (World Health Organisation) and US FDA (Food and Drug Administration) is that they do not recommend it to be used as a quit smoking agent. According to him, it has not been licensed in any country as a quit smoking agent because these devices have not gone through any rigorous clinical trials to be considered for that purpose.
“There are at least two studies that have shown it to be possibly useful but these studies have been small and the devices used are now considered outdated.
“The other issue that we have is the liquid used in these electronic nicotine delivery devices is not regulated, so we do not know what’s inside it.
“That is of concern healthwise because we don’t know what people are adding into the liquids,” he says, explaining that the technical taskforce at the Ministry of Health is expected to come up with a decision about the use of e-cigarettes in the country.
Putting on weight
When giving up smoking, some people may put on weight, informs Dr Amer.
Nicotine is a stimulant and it increases metabolism. So, when you stop smoking, your metabolism decreases a bit, and you might gain a bit of weight.
Could it also be a case of switching addictions – from cigarettes to food?
According to Dr Amer, there is no study to support this theory, however people do tend to snack a lot because when they quit smoking, their sense of smell and taste returns.
When someone gives up smoking, he often finds he is restless for something to do with the extra time and he has become used to the ritual of smoking. Some may indeed substitute the cigarette for snacks.
“Some may have severe weight gain. The current evidence is up to 5kg. The recent research shows that some people might gain even more weight. That’s definitely something that people don’t want. So, if they are going to gain weight, they will be more afraid to quit.
“With aid, the research shows that the weight gain is not there, and of course with followup support we are able to identify this problem and assist patients to ensure that whatever weight gain there is is minimal and hopefully when they manage to sustain quit, they can make other lifestyle changes to make sure that that doesn’t happen,” says Dr Amer.
Some may be able to quit quickly, others may take a bit longer, while some will quit and relapse.
“With aid, generally, if they are able to quit within the first three months, that means not even a puff for three months, then studies show that they are more likely to be able to sustain that quit attempt,” says Dr Amer.
He says it may sometimes take a few attempts before the individual is able to quit smoking, so they should not give up if they can’t quit after giving up smoking for a day or a week.
“What we need to get across is that for every attempt that they make, they definitely learn something from that attempt. Provided that the quit attempt was quite uneventful, they are more likely to consider attempting to quit again, compared with if the attempt was eventful, such as with a lot of withdrawal symptoms.
“I have patients who are so irritable that they lose their families. We don’t want that to happen. Some might have undiagnosed depression and they might be severely depressed when they quit smoking,” says Dr Amer, who welcomes the move by the Ministry of Health to expand the smoke-free areas in the country.
He believes this will assist those who want to quit smoking or are considering quitting. In societies in the West where smoking is not the norm, people find it easier to quit because it is not socially acceptable. Dr Amer says, that’s the kind of message we want to get across.
“Quitting is not that difficult. There are a lot of healthcare providers who are able to assist and at UM we are training as many individuals to assist Malaysians who want to quit smoking,” says Dr Amer.