SINGAPORE — At 21, Dexter Ng was already a prolific chain-smoker finishing up one-and-a-half packets of cigarettes — or about 30 sticks — a day.

Having come from a household of smokers, he smoked his first cigarette as a teenager after his cousin offered him one, and before that, he took his first puff of shisha at the age of 15 when a friend introduced it to him. Inhaling the sweetened tobacco bubbled through water pipes gave him a “huge kick”, he recalled.

Then, he started feeling the effects of being a heavy smoker. His voice changed. It sounded huskier and he was losing his voice more frequently. He also thought he tasted blood in his throat.

He friends, who are also smokers, would show him videos of heavy smokers who lost their voices. He used to think it was a joke and not real, until he started experiencing those changes.

That was when he decided that he needed to stop.

He tried going cold turkey on his own, used nicotine patches and chewed gum, but found that these methods do not work for him.

Compared to how easy it was to pick up smoking, it was not so easy kicking the habit. Especially when he had to do it on his own.

Mr Ng relied on smoking to manage his stress. Whenever he felt anxious or was unable to sleep, he would smoke. This suggested some form of psychological dependence.

Last year, he underwent a surgical procedure at Changi General Hospital (CGH) for an unrelated medical condition — which he did not want to reveal — and a door was opened for him to quit with some help and support.

The doctor he was seeing at the time referred him to the hospital’s smoking cessation programme.

Since then, he has kept away from smoking for more than six months. Chiefly because of the thought that he would be letting down the “very nice” people at CGH’s programme who are helping him to quit.

Besides equipping him with strategies and advice, the programme’s “certified quit smoking consultants”, as they are called, would regularly follow up with him by calling him on the phone — supportive measures that Mr Ng found helpful in sustaining his motivation to quit.

“For example, they would remind me not to fall for the ‘one-stick’ trick of rewarding myself with one smoke after a period of abstinence, which was one of my struggles.

“Every time I was tempted to light up again, I would think about how paiseh (embarrassing) it would be at my next appointment to disappoint the people trying to help me quit. But of course, you must want to quit for it to work.”

WHY IT’S SO HARD TO STUB OUT FOR GOOD

Smoking is one of the biggest risk factors for poor health, but it is also one of the most preventable causes of death.

The nicotine present in cigarettes works like a drug, making the smoker dependent on it and resulting in addiction. People are addicted when they still smoke even though they know that smoking is bad for them and is affecting their lives, health and families in unhealthy ways.

When they stop smoking, the addicted smokers suffer physical and emotional or psychological withdrawal symptoms. These symptoms include irritability, nervousness, headaches and trouble sleeping.

These symptoms, along with social reasons and the lack of support, can make it challenging for them to sustain motivation to quit.

There are medications to help with the nicotine dependence, but that would address only part of the problem.

Mr Mah Choon Siong, senior pharmacist at the National Healthcare Group (NHG) Pharmacy, said: “Some find it hard to quit due to their working environment or social activities that trigger their urge to smoke. These reasons are often harder to address than just the nicotine addiction.”   

Often, there is a psychological aspect to smoking dependence.

Ms Lum Yeow Chun, nursing coordinator at the specialty nursing unit at CGH and a certified quit smoking consultant, said that the younger generation, for example, generally pick up smoking due to curiosity or family or peer influence, while adults tend to smoke when they face emotions such as anger, anxiety, stress, fatigue and sadness.

“The adults feel that smoking gives them an immediate sense of relaxation,” she said.

“Older smokers on the other hand, would have smoked for many years, about 30 years or more, and they believe they cannot quit.”

These seniors smoke out of boredom, loneliness, frustration over domestic or financial issues, or are just resistant to change even though they have health problems.

“Some believe wrongly, based on what their friends tell them, that they will die when they quit smoking,” Ms Lum said.

Experts said that misconceptions can certainly sabotage efforts to quit smoking.

Ms Sandra Xu, senior pharmacist at NHG Pharmacy, said that some smokers have the misconception that there is a “magic bullet” to curb smoking.

There is no magic. The success rate is higher when medication goes along with behavioural support interventions, such as changing the smoker’s habits and reducing psychological dependence on cigarettes.

Some people also think that there is no sense in giving the body nicotine via nicotine replacement therapy when smokers are trying to quit the addiction, but Ms Xu pointed out that this therapy is a proven treatment method.

“The nicotine present is of pharmaceutical grade and does not contain the harmful chemicals found in cigarettes. This allows smokers to address their cravings and avoid withdrawal symptoms, while avoiding the inhalation of these harmful chemicals,” she said.

HOW SMOKERS WILL GET MORE SUPPORT

Smokers here will soon get more support in new smoking cessation pilot programmes, with full subsidies given for nicotine replacement therapy to those who are eligible.

Mr Amrin Amin, Senior Parliamentary Secretary for Health, announced the initiative earlier this month in Parliament during the budget debate for the Ministry of Health. 

The pilot programmes will be rolled out at public healthcare institutions. They include hospitals, polyclinics and national speciality centres after they resume normal operations, depending on how the Covid-19 pandemic develops.

The programmes will target 10,000 smokers, and Singaporeans can benefit from intensive behavioural support, follow-up for up to a year, and a three-month nicotine replacement therapy.

Other efforts to deter smoking include standardised packaging for tobacco products from July 2020, and raising the minimum legal age for smoking to 21 next year.

HOW SMOKERS ARE IDENTIFIED FOR PROGRAMME

Smoking cessation experts said studies show that behavioural support interventions and pharmacotherapy help improve quit rate, especially when they are used in combination. 

Such methods are being used in some smoking cessation programmes here to help patients as young as 13 years old to quit smoking.

Besides an outpatient smoking cessation clinic, CGH runs an inpatient programme that involves opportunistic screening of the smoking status of patients admitted to the hospital.

There are around 600 inpatients and 300 outpatients on the programme, with patients aged 15 to 93 years. About half are heavy smokers, which is defined as smoking at least 20 sticks a day.

Dr Jason See, smoking cessation lead and consultant at CGH’s cardiology department, said that smokers might be more open to receiving help and advice during their hospital stay.

Ms Lum, the certified quit smoking consultant, said that each hospitalisation is a “golden opportunity” to explore the patient’s biographic and social background, and understand the reasons for smoking and failed attempts to quit smoking.

Patients who agree to be enrolled into the programme are provided intensive counselling by the consultants.

This is followed by support given over phone calls at regular intervals after discharge.

Dr See said that smokers can be referred to the outpatient smoking cessation clinic for further review and pharmacological aids.

Ms Lum said that if required, they may also be referred to relevant agencies or professionals such as medical social workers, addiction counsellors, psychologist or psychiatrist.

Smoking cessation services are also available at NHG pharmacies in NHG Polyclinics and National University Polyclinics, which have reached out to about 2,000 smokers aged 13 to 78 years old since 2013.

Mr Mah of NHG Pharmacy said that these smokers are most commonly referred by doctors and care managers, or nurses who manage chronic conditions.

WHAT THE TEAM FOUND   

CGH’s inpatient smoking cessation programme found that a substantial proportion of patients have smoking-related medical conditions.

For example, about one in five have known heart disease, around one in four have respiratory conditions such as chronic obstructive pulmonary disorder and 8 per cent had previous strokes, Dr See said.

Quitting smoking would help cut down health risks.

For example, the risk of heart attack decreases by half after one year and the risk of stroke is reduced to that of a non-smoker after five years, Dr See added.

The risk of dying from lung cancer is half that of a smoker after 10 years of not smoking.

WHAT SMOKERS LEARN

At a smoking cessation programme, smokers are supported by consultants such as Ms Lum, to develop coping strategies and methods that are unique to them.

Strategies used would depend on the person’s type of smoking dependency, as well as reasons and barriers to quitting. 

For instance, for smokers who smoke to manage their stress, they would be taught breathing exercises and other stress management skills while those derive pleasure from a nicotine high may explore nicotine replacement therapy, the NHG Pharmacy experts said.

Although Mr Ng has gone off smoking for more than half a year, he hesitates to say that he has truly quit the habit.

“I still have ‘on-and-off’ urges to light up. But over time, it gets easier to resist. For me, I find that having some hard candy helps,” he said.

As for the throat symptoms that he had experienced earlier, Mr Ng said that they seem to have disappeared.

“I breathe better, have less phlegm and don’t have an itchy throat. I also feel less anxious, although I’m not sure why as I used to rely on smoking to manage stress. Overall, I just feel better,” he said.