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Jakarta Post

Smoking catch-22: Time to kick the habit?

Smoking catch-22: Time to kick  the habit?
Jenny Denton
Jakarta   ●   Wed, February 19, 2014

A journey to quit cigarettes in a tobacco-clinging city.

'€œIf you have good motivation to stop smoking, use it,'€ says smoking cessation expert Tribowo Ginting. '€œDon'€™t avoid it, don'€™t neglect it. Just follow your heart and do it. Everybody can stop.'€

According to the psychiatrist, 30 percent of people who try to stop smoking will do so by themselves, while another 70 percent need help and support.

The World Health Organization estimates that 400,000 people die as a result of tobacco use every year in Indonesia. While only 5 percent of Indonesian women smoke, 65 percent of men do and more than 97 million non-smokers are regularly exposed to secondhand smoke.

As a country, Indonesia is still heavily dependent on tobacco '€” in terms of the number of smokers and the industry'€™s economic impacts '€” despite efforts that have been made to reduce this. One of the many problems is smokers getting help to stop the habit.

For those who do want help to quit, one place to find it is at Persahabatan Hospital in East Jakarta, where Ginting and a colleague established a smoking cessation clinic that has been running since 2008.

The clinic is open to anyone and offers patients three months of treatment, incorporating medical checks, counseling '€” individually, in groups and with family '€” and the options of hypnotherapy and medication.

'€œIt'€™s a one-stop service,'€ claims Ginting, with infectious enthusiasm.

'€œFirst we will ask the range of your motivation, from zero '€” which is no motivation at all '€” to 10, which is full motivation.'€

While someone who rates their motivation at nine is unlikely to be prescribed medication, a person whose score is six or seven is considered to be in a '€œcontemplation'€ or '€œambivalent'€ phase and needs more assistance.

'€œIn the first counseling session we try to explore the problem that made the patient start to smoke,'€ Ginting explains. '€œMaybe they had depressive feelings or had a problem in their family, so they began smoking to try to relieve their problem and we try to counsel them about that. After that, in the second session, if there is no development or recovery at all we try to help them with medication.'€

The only currently available legal medication for smoking cessation in Indonesia is Varenicline, a drug sold in the form of a pill under the brand name Champix, which acts on the nicotine receptors in the brain to reduce cravings for cigarettes and decrease their pleasurable effects.

According to Ginting, a study of patients at the Persahaban Hospital clinic found that 60 percent of people who completed the program using Champix succeeded in stopping smoking, compared to 40 percent of those who did not take it.

But while the Persahaban Hospital program is affordable, Champix does not come cheap. Technically it is available only by prescription and should be taken under medical supervision, doctors say. In fact the drug is sold over the counter at some pharmacies, ranging in cost from Rp 300,000 (US$25) to Rp 1 million for a month'€™s supply. Ideally it should be taken for several months.

In many Western countries the armory of smoking-cessation treatments includes nicotine replacement therapies '€” patches, gum, inhalers and lozenges '€” that dispense a substitute dose of nicotine to the person trying to quit, but these are so far unavailable in Indonesia. While Ginting is wary of this treatment option, which can lead to the patient merely substituting one kind of addiction for another, it might work for some people, he says, because different treatments fit the needs of different people.

That view is echoed by hypnotherapist Rizal Darmawan, whose clinic in South Jakarta promises clients freedom from all manner of phobias and addictions.

'€œEvery client is different because every human is unique,'€ Rizal says. A good hypnotherapist should take a gradual approach and explore a client'€™s underlying psychological issues, not apply a one-size-fits-all technique.

Over the course of four one-hour treatments, the US-trained hypnotherapist explores previous and even past-life experiences with a client in order to '€œsolve problems'€ related to their smoking habit. He describes, for example, taking a 50-year-old man back in time to junior high school and helping him '€œchange'€ his decision to start smoking.

Rizal'€™s technique doesn'€™t involve reprogramming patients to feel sick when they smoke or to have negative attitudes about the habit, he emphasizes. Rather, he introduces healthy, positive messages into the client'€™s thinking, based on their own reasons for stopping smoking, and works with them to gradually reduce their tobacco consumption.

While research on the effectiveness of hypnotherapy alone as a smoking cessation strategy is inconclusive, it is obviously effective for some.

Whatever the treatment, it is clear that what is needed for success is genuine motivation.

'€œIf someone comes to me because their wife brings them and they don'€™t really want to stop, it is very difficult to get them to stop smoking,'€ Rizal says.

But, according to Ginting, seeing the relief and gratitude of the wives and families of people who do quit is one of the most rewarding things about his work at the clinic.

In a nation where cigarette companies sponsor everything from programs for schoolchildren to political parties, it is hard to make headway in the fight against the habit, public health advocates say. However, according to Yayi Suryo Prabandari from Quit Tobacco Indonesia, tobacco control is gradually being introduced in the archipelago and awareness of the dangers of both active and passive smoking is growing.

More than 100 cities and regions have introduced smoke-free areas since the 2009 national health law providing for them was passed, Yayi says, although enforcement of these is obviously still a problem.

So too is the power of big tobacco, she says, which is '€œvery, very aggressive'€ in its advertising and efforts to thwart policies that would affect the massive cigarette market here.

In Indonesia a scattering of organizations and services are doing their best to campaign against the companies'€™ influence and help people free themselves from the dangerous habit.

'€œIt'€™s difficult to change the culture. In Indonesian culture people give a cigarette as a gift, give a cigarette as part of a party, buy cigarettes to help a person be happy. But I believe we can change this if the regulations, if the policy, is fixed,'€ Ginting says.

Treatment options

Smoking cessation clinic (Persahabatan Hospital)
Treatment: Three months of counseling from a psychiatrist, in individual, group and family situations, with the options of in-house hypnotherapy and acupuncture treatment and of prescribed medication (using Champix) to reduce the desire to smoke.

Minimal cost for attending clinic but Champix costs between Rp 300,000 (US$25)and Rp 1 million per month and should be taken for several months.

Success rates: 60 percent of clients who complete the program using medication successfully stop smoking.

Hypnotherapy (Rizal Darmawan'€™s clinic)
Treatment: A package of four sessions of up to one hour each, over the course of which cigarette consumption is gradually reduced. Client'€™s reasons for wanting to stop smoking and previous experiences are explored in order to solve problems related to the habit and introduce positive messages based on the individual'€™s desire to stop smoking.

The results of research on the use of hypnotherapy alone to help people stop smoking are inconclusive.

Cost: Rp 2.5 million for four sessions at Rizal'€™s clinic, but hypnotherapy prices vary widely.

Acupuncture (Indera Wirawan'€™s clinic)

Treatment: Three sessions during which patients are counseled about their addiction from a multi-faith religious perspective and fine needles are inserted into the skin around the base of the nostrils, the lung points on the chest, the back of the shoulders and the base of the skull to clear the lungs and improve circulation. Small magnetic needles that stay in place for a day or two are inserted into clients'€™ ear lobes and can be pressed to release serotonin when the urge to smoke strikes. Indera also often recommends accompanying strategies such as the use of nicotine patches and Kopiko coffee candy.

Cost: Rp 300,000 per treatment session

Effectiveness: Likely to be helpful in combination with other strategies. Research results are so far inconclusive.

Laser therapy (S Clinic '€”

Treatment: A package of a one-hour and two 30-minute sessions. A low-level, '€œnon-invasive'€ laser is applied to '€œaddiction points'€ and acupuncture points on the hands, face, wrist and ears. The treatment is said to work similarly to acupuncture, detoxifying the body of nicotine and making cigarettes taste bitter.

Cost: Rp 2 million for three sessions.

Effectiveness: The clinic'€™s claim of an '€œup to 94 percent success rate'€ is too good to be true. Health authorities say there is no clear evidence to confirm the effectiveness of laser treatment for smoking cessation. But people with high motivation to quit who want to try laser therapy may find that it helps them do it.

The writer is an intern at The Jakarta Post.