Tobacco & nicotine

What is tobacco and nicotine addiction?

Tobacco addiction, known medically as nicotine dependence or tobacco use disorder, is when a person finds it hard to stop using tobacco even though they know it is harming them. Nicotine, the chemical in tobacco that causes addiction, reaches the brain quickly and releases “feel-good” signals. Over time, the brain comes to expect it. Without it, the person feels restless, irritable and unable to concentrate, and tobacco seems to fix those feelings.

This is why so many people say, “I know it’s bad for me, but I can’t leave it.” It is not a weakness of character. The World Health Organization describes nicotine as highly addictive, and its classification of diseases, ICD-11, recognises disorders due to nicotine use as health conditions.

Tobacco use is very common in India. The second Global Adult Tobacco Survey (GATS 2, 2016–17) found that 28.6% of adults, about 26.7 crore people, use tobacco in some form. Among men the figure was 42.4%, and among women 14.2%. The good news from the same survey: more than half of smokers (55.4%) said they were interested in or planning to quit.

Forms of tobacco used in India

India has a wider range of tobacco products than most countries. All of them contain nicotine, and all of them harm health.

Smoked tobacco

• Cigarettes and bidis. Bidis are used by 7.7% of adults and are sometimes wrongly seen as milder.
• Hookah, including in cafés and at gatherings, where flavoured tobacco can make the smoke feel harmless.

Smokeless tobacco

• Khaini, a mixture of tobacco and lime, is the most commonly used tobacco product in India, used by about one in nine adults.
• Gutkha, a mixture of tobacco, lime and areca nut, is used by 6.8% of adults.
• Zarda (flavoured tobacco, often in paan), mawa (tobacco with areca nut and lime), tobacco in betel quid, and tobacco tooth powders.

Overall, about one in five adults in India (21.4%) uses smokeless tobacco, compared with about one in ten who smoke.

E-cigarettes and vapes

E-cigarettes heat a nicotine liquid into a vapour. They are often marketed with fruity flavours and sleek designs that appeal to teenagers and young adults. In India, the Prohibition of Electronic Cigarettes Act, 2019 bans the manufacture, import, export, transport, sale, distribution, storage and advertisement of e-cigarettes. The World Health Organization states that e-cigarettes are harmful to health and are not safe.

Signs of nicotine addiction

You may be dependent on nicotine if you notice several of these:

• Using tobacco within a short time of waking up
• Strong cravings, especially with tea, after meals or during stress
• Feeling irritable, anxious or unable to focus when you can’t use it
• Trying to cut down or quit and going back within days or weeks
• Using more over time, or finishing a packet or pouch faster than before
• Continuing despite a cough, mouth problems, breathlessness or a doctor’s advice
• Planning your day around smoke breaks or keeping a supply at all times
• Using in places where it is not allowed or hiding use from family

In GATS 2, 58.5% of daily tobacco users in India used tobacco within 30 minutes of waking, a common sign of dependence.

How tobacco affects health

According to the World Health Organization, tobacco damages nearly every organ in the body. It causes cancer, heart disease, stroke, lung disease, reduced fertility, weakened immunity and early death. Worldwide, it kills more than 7 million people each year, including over 1.6 million non-smokers exposed to second-hand smoke.

Smoking raises the risk of:

• Heart attack, stroke and poor circulation in the legs
• Long-term lung disease (COPD), with breathlessness and a lasting cough
• Cancers of the lung, mouth, throat, food pipe, bladder and other organs
• Worse control of diabetes and slower healing

Smokeless tobacco (gutkha, khaini, zarda, mawa) causes:

• Oral cancer, as well as cancer of the food pipe and pancreas
• Gum disease, tooth damage and stained teeth
• Leukoplakia, white patches in the mouth that can turn cancerous

Tobacco and areca nut are among the major causes of oral cancer. Spotting early warning signs matters.

Second-hand smoke harms family members, especially children, who may develop more chest infections and asthma attacks.

Warning signs in the mouth

If you use any form of tobacco, see a doctor or dentist promptly if you notice:

• A mouth ulcer or sore that does not heal within two weeks
• A white or red patch inside the cheeks, gums or tongue
• A lump or thickening in the mouth or neck
• Stiffness or difficulty opening the mouth
• A burning feeling with spicy food that keeps coming back

Most of these are not cancer, but early checks catch problems when they are easiest to treat.

Nicotine withdrawal and cravings

When you stop, your brain has to adjust to working without nicotine. This is uncomfortable but not dangerous. Common symptoms include:

• Strong cravings
• Irritability, frustration or short temper
• Restlessness and anxiety
• Difficulty concentrating
• Low mood
• Increased appetite
• Disturbed sleep

Symptoms are usually strongest in the first week or two and ease over the following weeks. Individual cravings come in waves and usually pass within a few minutes. Treatment makes this phase far easier, which is why quitting with support is more successful than going it alone.

Tobacco, stress and mental health

Many people feel that a cigarette or a pinch of khaini calms them down. Much of that calm is actually relief from nicotine withdrawal that built up since the last use. Once withdrawal settles, many people find they feel no more stressed than before.

People with depression, anxiety, schizophrenia, bipolar disorder or other substance use often use tobacco heavily and may find quitting harder. They can quit successfully with the right support. Stopping smoking can change how some psychiatric medicines work in the body, so tell your psychiatrist before you quit so doses can be reviewed if needed. If quitting brings on very low mood or thoughts of self-harm, seek help straight away.

Young people and parents

Most tobacco use starts young. In GATS 2, the average age at which people in India started using tobacco was 18.9 years, and many begin much earlier. The World Health Organization notes that nicotine is especially harmful for children, adolescents and young adults, whose brains are still developing.

Despite the ban, vapes still reach teenagers through friends and online. Parents may notice a sweet smell, small USB-like devices, pods or unusual chargers, or tobacco pouches and a changed smell on breath or clothes. A calm conversation works better than anger. Under-18s are seen together with a parent or guardian.

When to see a psychiatrist

Consider speaking to an addiction psychiatrist if:

• You have tried to quit before and gone back
• You use tobacco soon after waking or feel you can’t get through the day without it
• You have heart, lung, mouth or diabetes problems and need to stop
• You also have depression, anxiety or another mental health condition
• You use alcohol, cannabis or other substances along with tobacco
• You use tobacco to cope with stress, low mood, loneliness or boredom
• You are planning a pregnancy or surgery and want to quit safely

How nicotine addiction is assessed

The first consultation is a practical conversation. The psychiatrist will ask what forms of tobacco you use, how much and how soon after waking, past quit attempts and what went wrong, withdrawal symptoms, triggers, physical health, mood, sleep, other substances and medicines. With your permission, a family member can join part of the discussion. Together you set a goal and choose a treatment plan, and follow-up visits check how you are managing cravings, mood, sleep and any side effects of medicines.

Treatment

The World Health Organization recommends combining behavioural support with medicines, which can more than double the chance of quitting.

1. Behavioural support and a quit plan

Counselling helps you understand your pattern of use and prepare to stop. A good quit plan usually includes:

• Setting a quit date, ideally within the next two weeks
• Knowing your triggers, such as tea, meals, work breaks, stress, alcohol or certain friends
• Planning alternatives for each trigger, such as a short walk, chewing fennel seeds (saunf) or calling someone
• Clearing out cigarettes, bidis, pouches, lighters and ashtrays from home, car and office
• Telling family and colleagues so they can support you
• Planning for difficult moments, such as weddings, travel or a stressful day

Follow-up sessions, in person, online or by phone, help you stay on track. Brief advice, individual or group counselling, and text-message or app-based support all have evidence behind them.

India’s National Tobacco Quit Line, run by the Ministry of Health and Family Welfare, offers free counselling: call 1800-11-2356 (toll-free) or give a missed call to 011-22901701.

2. Nicotine replacement therapy (NRT)

Nicotine replacement therapy, such as patches, gum or lozenges, provides nicotine without the smoke and other harmful chemicals in tobacco. It eases cravings and withdrawal while you break the habit, and the amount is reduced gradually over weeks. Some people use a combination, for example a patch for steady background relief and gum for sudden cravings. Your doctor will advise which form and plan suit you.

3. Other stop-smoking medicines

There are also prescription medicines that do not contain nicotine. They work by reducing cravings and withdrawal, and by making tobacco feel less rewarding if you slip. Your psychiatrist decides whether they suit you based on your health and other medicines, and monitors you while you take them. Stop-smoking medicines must only be started, changed or stopped with a doctor.

4. Treating other conditions together

Depression, anxiety, alcohol or cannabis use and sleep problems can make quitting harder. Treating them at the same time, known as dual diagnosis care, improves the chance of staying tobacco-free.

Outpatient and online care

Tobacco treatment rarely needs a hospital stay. Most people are treated as outpatients or online, with regular follow-up over the first few months. Dr. Tarwani sees patients at Sukoon Health in Gurugram and South Delhi, and online.

Recovery and relapse

Quitting is a process. The first few weeks are hardest, and relapse is most common in the early months, often during stress, celebrations or drinking.

A slip (one cigarette or one pouch) does not have to become a full relapse. Don’t treat it as proof you can’t quit. Get back on track the same day, think about what triggered it, and adjust the plan with your doctor. Needing more than one attempt is common. The health benefits of quitting begin soon after stopping and keep growing over the years, at any age. Quitting also saves money that can go towards family needs, and it protects children from second-hand smoke and from growing up seeing tobacco as normal.

For families

Watching someone you love use tobacco can be worrying, especially when you see their cough or breathlessness. A few things help:

• Encourage rather than nag, and choose a calm moment to talk
• Focus on specific concerns (“I worry when I hear you coughing at night”) rather than blame
• Keep the home and car smoke-free to protect children
• Help remove tobacco from the house on the quit date
• Be patient with irritability in the first weeks
• Celebrate milestones, such as one week or one month tobacco-free

You are welcome to consult Dr. Tarwani first, on your own, to plan how to support your loved one.

Common myths

• “Bidis are more natural and less harmful than cigarettes.” Bidis contain tobacco and nicotine and cause the same kinds of harm.
• “Gutkha and khaini are safe because there is no smoke.” Smokeless tobacco causes oral cancer, gum disease and addiction.
• “Hookah is just flavoured water vapour.” Hookah uses tobacco, and the smoke contains nicotine and harmful chemicals.
• “Vapes are harmless and help everyone quit.” WHO states e-cigarettes are harmful and not safe, and they are banned in India.
• “I’ve smoked for 30 years, the damage is done.” Quitting brings health benefits at any age.