On 31 May 2018, the World No Tobacco Day 2018 coincides with the fasting month of Ramadan. Fasting requires abstinence from smoking as well as eating and drinking during the day, and the month of Ramadan provides an ideal opportunity for smokers to quit.

Associate Professor Mohamed Haniki Nik Mohamed, PharmD, shares how Ramadan creates a conducive environment for people, especially Muslims, to quit smoking.

Questions

1. Could you tell us a little more about your role in the Malaysian Academy of Pharmacy’s smoking cessation programme?

I am the chief coordinator of the Certified Smoking Cessation Service Programme (CSCSP) under the Malaysian Academy of Pharmacy, of which I’m the principal.

The programme was established to equip healthcare providers with additional skills and knowledge regarding smoking cessation, intervention and providing quit smoking service.

We are targeting the main pool of clinicians because we realize that they are the main players who see patients at various opportunities. In hospitals or clinics, patients would see doctors, pharmacists and nurses whereas in a community setting, GPs and community pharmacists are involved. There are also dentists who have the unique opportunity to help smokers when providing oral care as they would definitely see the staining effect of tar and nicotine on the teeth, as well as signs of other diseases that are related to tobacco use.

2. How does the fasting month of Ramadan provide a conducive environment to quit smoking?

One of the roadblocks to quit smoking is the incessant smoking environment, in which smokers would be seeing other smokers in action, as well as being exposed to second hand smoke.

Additionally, eating and drinking are associated with smoking because the act of smoking is used to enhance pleasure through the release of dopamine vis-à-vis the activation of the reward pathway and the nicotine effect.

When coupled with pleasurable activities such as eating and drinking, this sense of pleasure will inevitably be heightened or enhanced. For someone who has been doing this for many years, it's like an enforcement behaviour. You drink, you smoke. You eat, you smoke.

In the absence of eating and drinking during Ramadan, it actually helps to reduce, or possibly eliminate, smoking triggers for at least 12–13 hours

3. In your opinion, is Ramadan the best time for smokers to begin their smoking cessation programme?

Definitely. The beauty of Ramadan is that it provides a 180-degree change in environment; it helps smokers to not smoke for at least 12-13 hours during the day.

When we look at the behaviour component in a smoking cessation programme, there are many theories on how to change behaviour – one is the Transtheoretical Model of Behavioural Change by Prochaska and Diclemente. They proposed that people change their behaviour from Precontemplation to Contemplation, followed by Preparation, Action and Maintenance; they can go in and out of these distinct stages at different times, and Ramadan is definitely a strong push or motivator for people to get prepared and take action. If they choose Ramadan as the quit date, then they would be in the 'Action' phase.

As such, advise them to just continue pushing through the additional hours to make it a whole day, then a whole week, and a whole month. Some people need that kind of motivation.

4. How can HCPs encourage smokers to use the fasting period during Ramadan as an opportunity to take the first steps towards quitting their smoking habit?

The last part of the 5 A’s intervention steps (ie, Asking, Advising, Assessing, Assisting, Arranging for follow-up) is arranging for follow-up sessions. You should try to see your patient every week in the first month because that's the most crucial or worst month for a smoker initiating smoking cessation. Withdrawal symptoms are worse during the first 2 to 4 weeks; some smokers will experience a longer withdrawal period, with an increase in appetite.

In terms of following up on those who attempt to start smoking cessation within a 1-month period, it actually works very nicely with Ramadan because – if strengthened or reinforced by the positive environment during Ramadan – someone who can get through Ramadan without smoking has a higher success rate of quitting smoking successfully at six months.

5. How can smokers maintain their motivation beyond the month of Ramadan?

If they need help, always seek from certified HCPs. Get help from people who can support their process of quitting smoking, eg family, friends, colleagues or even bosses.

Always anticipate triggers and problems, and keep in touch with HCPs to prevent relapse.

I had patients who were already defined as a quitter but came back to the clinic asking for medications. They said that as they are going back to their hometown for Hari Raya and will be seeing their friends, whom they started smoking with, meeting these friends would somehow provide a trigger for them to start smoking again.

We advise the smokers to be assertive when responding to a cigarette offer. Being assertive means that you voice your opinion without hurting the listener. For example, they can say “No thank you, I have quit smoking”.

If they can continue the motivation gained during Ramadan for the rest of the 10 months of the smoking cessation programme, that would be the best thing to do. Advise patients to always perform voluntary fasts outside of Ramadan or attempt intermittent fasting. This way they will have a continuous attachment to the practice of Ramadan fasting, which creates a positive environment and provides that long-lasting motivation to quit smoking. I think that would be one of the best approaches to quitting smoking successfully. MIMS

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Read more:
Breaking the habit: Mohamad Haniki Nik Mohamed on smoking cessation
World No Tobacco Day: Health, economic, environmental threats due to smoking
The struggle against smoking and the growing threat of e-cigarettes in Hong Kong
Singapore amends Tobacco Act for a smoke- and nicotine-free nation