South Asian Smokeless Tobacco Products:

Addiction and Withdrawal

Pratima MurthyProfessor and Head

Department of Psychiatry, NIMHANS, Bangalore, India

• SEAR has double burden of high prevalence of smoking (1 in 5) and SLT use (1 in 5).

• Among women tobacco users globally, SLT is the predominant form of tobacco used. SLT use is higher in rural areas (1.25-3 times) and in the poorest communities (3-17 times) in SEAR and African Region.

• Unusually SLT use among adolescents in SEAR is higher than smoking.

2017

The problem of smokeless tobacco

• Its use is normalised in most societies

• Betel quid is one of the most widely used form of tobacco in the world

• Cheap and easily available

1

2

90.2

92.4

88.8

95.6

Belief that tobacco use causes serious illness

Belief that SMT causes serious illness Belief that smoking causes serious illness

1= GATS 1 ( 2010); 2=GATS 2 (2016)

Do more SMT users want to QUIT?Yes….But...

12.6

4.8

16.2

12.1

4.6

5.2

16.8

5.8

17.6

16.8

5.2

7

Former daily smokers among past smokers All

Former daily SMT users among past SMT users ALL

Former daily smokers among past smokers female

Former daily smokers among past smokers male

Former daily SMT users among past SMT usersMale

Former daily SMT users among past SMT usersFemale

GATS 2 GATS 1

Gutka Ban

• With the ban on Gutkha in India, there has been a reduction in Gutkha use from 7% to 6%. However, in spite of a complete ban on SLT in Bhutan, there is an increasing use of SLT among adolescents.

• Clinical experience – initially positive trend. Hardened users combine pan masala and tobacco pouches

• Gutka available at a premium

User/KI perceptions of SMT use

• “Switching” from smoking

or alternative to smoking

• Can “Chew and Work”

• Financial perspective

• Point of sale advertising

EnjoymentTime passBoredom

Relief of tirednessMood relief

HabitEase of bowel

movement

Murthy et al 2018

Factors influencing SMT use and maintenance

Murthy et al 2018

Reward Pathway: core of all Addiction

• There is a axonal network in the brain labeled the ‘reward pathway’

• This reward pathway is activated by:

– Food, water and sex, activities (such as sky diving, paragliding etc) and exercise

This reward pathway is also activated by nicotineTobacco Cessation: A Manual for Nurses,

Health Workers and other Health Professionals: WHO SEARO Manual 2014 en.Wikipedia.org

Addictive power of Tobacco

• 100 times more than heroin , 1000 times more than cocaine

• Nicotine or Tobacco?

Tobacco Cessation: A Manual for Nurses, Health Workers and other Health

Professionals: WHO SEARO Manual 2014

Nicotine dependence

This is often referred to as addiction. This happens because of certain brain changes.

Features of addiction are:

• Craving: a strong desire to use the nicotine

• Withdrawal symptoms

• Increase and regular use

• Use despite harm

• Difficulty in controlling use

• Use despite knowing the harmful effects

DSM V and ICD 11 criteria for Tobacco use disorder/Dependence

DSM V

A. Larger quantities of tobacco over a longer period than intended

1. Unsuccessful efforts to reduce or quit2. Inordinate amount of time acquiring or using3. Craving4. Failure to attend responsibilities and obligations5. Continued use despite adverse social or

interpersonal consequences6. Forfeiture of social, occupational or recreational

activities in favour of tobacco use7. Tobacco use in hazardous situation8. Continued use despite awareness of physical or

psychological problems directly attributed to tobacco use

B. Tolerance for nicotine, as indicated by:

9. Need for increasingly larger doses of nicotine...

C. Withdrawal symptoms upon cessation of use as indicated by:

10. The onset of typical nicotine associated withdrawal symptoms

11. More nicotine or a substituted drug is taken to alleviate withdrawal symptoms

ICD 11

• Impaired control over substance use

• Substance use takes priority over other interests. Use continues despite occurrence of problems

• Physiological symptoms as manifested by tolerance, withdrawal and repeated use to prevent or alleviate withdrawal symptoms

Measurement of SMT Dependence

• Fagerström Tolerance Questionnaire for Smokeless Tobacco (FTQ-ST)

• Severson Smokeless Tobacco Dependency Scale (SSTDS)

• Glover-Nilsson Smokeless Tobacco Behavioral Questionnaire (GN-STBQ)

FTQ

• The FTQ measures physiologic and behavioral parameters of dependence.

• Cigarettes per day, time to first cigarette, frequency of inhalation, and questions relating to dependence behaviors (i.e., difficulty refraining from use). Among smokers, FTQ scores have been shown to significantly correlate with measures of carbon monoxide, nicotine, and cotinine, but the relation is less robust between FTQ scores and self-reported withdrawal symptoms (Fagerström& Schneider, 1989).

• Ebbert et al 2012

YES NO

1. After a normal sleeping period, do you use smokeless tobacco within 30 minutes of waking

1 0

2. Is it difficult for you not use SLT where its use would be unsuitable or restricted

1 0

3. Do you use SLT when you are sick or have mouth sores 1 0

4. Nicotine content Low -1, Medium- 2, High -3

5. How many days does a tin/can last you? 6-7 -1; 3-5 -2; 1-3 -3

6. On average, how many minutes do you keep a fresh dip or chew in your mouth?

10-19 -1; 20-30 -2; >30 - 3

7. How often do you swallow tobacco juices? Never – 0; Sometimes- 1;Always – 2

8. Do you keep a dip or chew in the mouth almost all the time? Yes -1; No-0

9. Do you experience strong cravings for a dip/chew when you go for more than 2 hours without one?

Yes -1; No-0

10. On average, how many dips or chews do you take each day? 1-9- 1; 10-15 – 2; >15 -3

The total score for FTQ-ST is calculated as the sum of the items (4-19)

GN Smokeless tobacco Behavioral Questionnaire (GN-STBQ)

Not at all Somewhat Moderately Very much Extremely

1. My smokeless tobacco is very important to me

0 1 2 3 4

2. I manouevre and manipulate SLT in my mouth as part of the ritual use

0 1 2 3 4

3. Place something in the mouth to distract from SLT?

0 1 2 3 4

4. Reward self with SLT after accomplishing a task

0 1 2 3 4

5. Feel that without SLT, will have difficulty concentrating before attempting a task?

0 1 2 3 4

*The total score for the GN-STBQ was calculated as the sum of the 11 items (0-44)

Never Seldom Sometimes

Often Always

6. If you are not allowed to use SLT in certain places, do you play with your SLT can or pouch?

0 1 2 3 4

7. Do certain environmental cues trigger your SLT use? 0 1 2 3 4

8. Do you feel yourself using SLT routinely (without craving) 0 1 2 3 4

9. Do you find yourself placing other objects in your mouth to get relief from stress, tension or frustration?

0 1 2 3 4

10. Does part of your SLT enjoyment come from the steps (ritual) you take when handling your SLT?

0 1 2 3 4

11. When you are alone in a restaurant, bus terminal, party etc, do you feel safe, secure, or more confident if you are in possession of SLT?

0 1 2 3 4

Severson Smokeless Tobacco Dependence Scale (SSTDS) – short form

1. How many days does a tin or pouch last you? <1 - >7

2. Do you experience strong cravings for a dip/chew when you go more than 2 hours without one?

Y-1, N-0

3. How soon after you wake up do you use chew/snuff? 0-30 -1; >30 min-)

4. When you go without a dip or chew, do you find yourself getting anxious more quickly?

N – 0; Seldom -1; Sometimes -2; Often -3; Always -4

5. When you go without a dip or chew, do you find yourself getting drowsy more quickly?

N – 0; Seldom -1; Sometimes -2; Often -3; Always -4

6. I use more snuff/chew when I’m worried about something.

Not at all – 0; A little – 1; Quite a bit – 2; Very much -3

7. I use more snuff/chew when I am rushed and have lots to do.

Not at all – 0; A little – 1; Quite a bit – 2; Very much -3

8. I get a definite lift and feel more alert when using snuff/chew

Not at all – 0; A little – 1; Quite a bit – 2; Very much -3

Total score sum of items 2-8 (0-19)

Correlations

• All scales were significantly correlated with ST cans consumed per week;

• (2) the FTQ-ST was significantly correlated with serum nicotine and urinary cotinineconcentrations and craving;

• (3) the GN-STBQ and SSTDS were significantly associated with both craving and withdrawal; and

• (4) none of the scales were significantly associated with ST abstinence.

Ebbert et al 2012

Challenge for cessation support – Variation in tobacco and nicotine content in commonly

used SMT products

Type of SMT Average tobacco weight/unit (g)

Average nicotine content mg/g tobacco

Mishri 50.5±0.70 5.03±0.07

Khaini 5.9±0.89 6.6±2.64

Kaddipudi 49.0±1.4 5.3±0.565

Tambaaku 5.7±3.9 13.7±7.6

Gutkha 2.0±0.92 3.2 5±0.7 0

Sharma, Murthy, Shivhare 2015

Revisiting what seemed to work for SMT use reduction

• Community education- Experience from Karnataka• More positive experiences with SMT• Addiction potential of tobacco

Murthy and Sahoo 2010

Low access to tools/aids to quit tobacco

• Apart from Text messaging only 15% [97/643] reported access to any other tools/aids for tobacco cessation

Of those who had received additional aids, • One- third reported Counseling/NRT; • One- fifth medications like Bupropion, traditional

medicines, access to a Quit Line or specific support for SMT Cessation (IIHMR 2017)

• NATIONAL TOBACCO QUITLINE- ENCOURAGING TRENDS

The Addiction Triangle and Coping Strategies

Kottayam 2009

Ebbertet al

2012

Brief advice for patients willing to stop tobacco use

Kottayam 2009

If the patient is prepared to stop, set out a plan of

action using the five steps of brief advice in primary

care settings — the Five ‘As’.

• Ask — about smoking and chewing habits

• Advise — that the patient quits use

• Assess — willingness to quit

• Assist — in devising a plan to quit

• Arrange — to see the patient again

25

Withdrawal from nicotine

26

Many smokeless tobacco users experience constipation, which is an often cited reason for continuing use

Pharmacotherapy

• 1st line pharmacotherapy medications include: – Bupropion SR– Nicotine replacement therapy

• nicotine gum• nicotine inhaler• nicotine nasal spray• nicotine patch.

– Varenicline

• 2nd line

– Clonidine and nortriptyline

– Selegeline, mecamylamine

Effectiveness of smokeless tobacco cessation interventions

• Variable duration of follow-up (1 month, 3 months, 6 months, 1 year)

• Behavioural interventions have shown considerable impact in many RCTs (0.87-3.72)

• Combination of NRT with BIs (0.73-1.73)(4.93*)

• Combination of Varenicline* with BI (1.33-1.42)

• Combination of Bupropion* with BI (0.87-2.73)

* 3 RCTs each, modest numbers for bupropion, larger numbers with varenicline

(Nathen et al 2018)

Better outcome for smokeless tobacco cessation- experience of TCCs

Bangalore

Chandigarh

Chennai

Cuttuck

Goa

Hyderabad

Mizoram

Trivandrum

9

1

15

2

65

8

25

31

32

1

15

9

76

9

12

41

Smokeless tobacco-percentage abstinent/reduced >50% at one year

1 year Smokeless 1 year Smokers

3459 smokeless tobacco users among 5976 total tobacco users (58%)

Steps for up-scaling smokeless tobacco cessation services

• Health provider focus on SLT in addition to smoking

• Integrating tobacco cessation with alcohol cessation in primary care (Sabari, Murthy, Kumar 2017)

• Packaging and display of ingredients

• Community engagement

• Oral examination

• Linkages with NCD programmes

• Towards an Ecological Model

• Using online platforms