Nicotine Replacement Therapy for the Palliation of Nicotine Abstinence Syndrome: Boon More than Bane

Sir,

Apropos, the article titled “Nicotine Replacement Therapy (NRT) for Palliation of Nicotine Abstinence Syndrome—Is it Worth?” in Indian Journal of Palliative Care (May − August issue)[1] questioning the worth of NRT for the management of nicotine abstinence (withdrawal) syndrome, we would like to express a difference of opinion. Nicotine use is one of the major public health disasters of the 21^st century which is still widely prevalent.[2] The burden of nicotine dependence can be judged from the fact that tobacco in smokeless or smoking form kills 5 million citizens globally every year. The World Health Organization (WHO) projects that the number of deaths will double within the next 15 years worldwide. Tobacco will subsequently be the leading cause of death in the developing world, as it already is in developed countries today.[3] In India too, the situation is not any better as tobacco use is associated with a substantial risk of cancers and by 2020 it is predicted that it will account for 13% of all deaths.[4] It is interesting to note that though tobacco-attributable mortality increases slowly after the initiation of smoking, the effects of cessation emerge more rapidly. Cessation is the only practicable way to avoid a substantial proportion of tobacco-attributable deaths in the world.[5] Unfortunately, there are only limited strategies available to fight this public health menace of global importance. NRT is one of the most commonly used, safe, effective, and evidence-based strategy for tobacco cessation.[67] All the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler, and sublingual tablets/lozenges) help people who make a quit attempt increase their chances of successfully stopping smoking. NRT significantly reduces nicotine withdrawal, and hence helps in palliation of nicotine abstinence syndrome. NRTs increase the rate of quitting by 50–70%, regardless of setting.[89] Large amount of misinformation exists regarding relative safety and harm of NRT. It is true that most common side effects associated with NRTs in clinical practice are:

• Skin irritation when using patches

• Irritation of nose, throat, or eyes when using a nasal spray

• Throat irritation, sore mouth, stomach discomfort, hiccups, jaw muscle ache, increased salivation, dizziness, and headaches when using nicotine chewing gums.

However, even after we assumed some harm from long-term NRT use, the benefits from cessation far outweigh the risks.[10] More effort should be made to increase awareness of the full spectrum of harm from tobacco use viz-à-viz potential risks from NRT use and attempts should instead be made to increase the use of this effective intervention for management of tobacco cessation.

Additionally in terms of cost effectiveness, smoking cessation has been termed ‘gold standard’ of healthcare cost effectiveness, producing additional years of life at costs that are well below those estimated for a wide range of healthcare interventions. Provision of NRT with an effectiveness of 1% is predicted to result in the avoidance of about 3.5 million smoking-attributable deaths. Of these, low- and middle-income countries would account for roughly 80% of the averted deaths.[1112] In the developing country like India where about 1 million deaths are expected in male smokers by 2025, NRT should be made easily accessible and subsidized with government run health services supporting the cost of cessation. The already existing National Tobacco Control Programme should be strengthened to support the incorporation of tobacco control efforts into the existing healthcare system.[1314]

Finally, all stakeholders, healthcare specialists including oncologists, palliative care specialists, and psychiatrists having witnessed the agony of patients and their caregivers, should attempt to promote the ancient principle: “An ounce of prevention is worth a pound of cure.”