Tobacco
Nobody calls this an addiction
A man who would be offended by the suggestion that he drinks too much will tell you, without embarrassment, that he has smoked twenty a day for twenty-two years.
A woman who has never touched alcohol in her life, who would not allow it in her house, has been using mishri since she was nineteen. Ten times a day, maybe more. She does not think of herself as using tobacco. She thinks of it as something she does for her teeth.
This is the strangest thing about tobacco in India. It is by a distance the most widely used dependence-forming substance we have, it kills more people than everything else on this floor combined, and it carries almost no shame — which sounds like a mercy and is actually the problem. Shame at least makes people ask.
The short answer
Tobacco dependence is a medical condition, not a bad habit. Nicotine acts on the brain quickly and repeatedly, and after some years of use the wanting is physical.
Smokeless tobacco — mishri, kharra, khaini, gutkha, mawa, tobacco in paan — is tobacco. It is not the safer choice it is believed to be, and in the mouth it is worse.
Unlike alcohol, stopping tobacco suddenly is not physically dangerous. Uncomfortable, yes. Dangerous, no. That difference matters and almost nobody knows it.
Willpower alone works for very few people. A quit date, the right medicine and someone to check in with works for a great many more — and this is, honestly, the most treatable condition on this floor.
What counts as tobacco
Worth listing plainly, because people genuinely do not recognise their own use.
Smoked: cigarettes, bidis, hookah, chillum, cigars.
Smokeless: mishri, kharra, khaini, gutkha, mawa, zarda, tobacco added to paan or supari, tobacco toothpaste and tobacco tooth powder.
If you read that second list and thought “mishri is not really tobacco,” you are in the majority, and this next part is written for you.
Mishri is tobacco
Mishri is tobacco, roasted or burnt and powdered, and rubbed on the gums and teeth. That is all it is.
It usually starts for a reason that has nothing to do with wanting a high — a toothache, a habit picked up from an aunt, the belief that it cleans the teeth or strengthens the gums. It does not clean anything. What it does is deliver nicotine through the lining of the mouth, steadily, many times a day, and it is absorbed perfectly well that way.
So the woman using mishri fifteen times a day is nicotine dependent in exactly the sense a smoker is. She has simply never been told, because nobody talks to her about it — not her family, often not her doctor, and certainly not any website.
And she is not unusual. Among women in Maharashtra, smokeless tobacco is far more common than cigarettes will ever be.
Smokeless is not the safer option
The belief that chewing is a milder version of smoking is widespread and it is wrong. It is a different set of harms, sitting in a different place — mostly in the mouth, where the tobacco is actually kept.
- Cancer of the mouth, tongue, cheek and throat. India carries an enormous share of the world’s oral cancer, and smokeless tobacco is the main reason.
- Oral submucous fibrosis — the lining of the mouth slowly stiffens. It begins as burning when eating anything spicy and ends with a mouth that will not open more than a finger’s width. It is not reversible, and areca nut in gutkha, kharra and mawa is central to it.
- Gum recession, loosening and loss of teeth, staining, persistent bad breath.
- In pregnancy, smokeless tobacco is associated with smaller babies and worse outcomes. This is not widely known and it should be.
- And the same things smoking does to the heart and blood vessels, because nicotine reaches the same places.
Gutkha has been banned in Maharashtra for years. What replaced it was people mixing the same components by hand at the counter. The ban changed the packet, not the mouth.
The signs in the mouth that need seeing this week
See a dentist or doctor without waiting if there is: A white or red patch inside the mouth that does not rub off. An ulcer or sore that has not healed in two weeks. Burning in the mouth with ordinary spicy food, when that never used to happen. The mouth opening less than it used to — difficulty putting in a full bite, or trouble at the dentist. A lump in the cheek, tongue or neck, a loose tooth with no dental reason, or bleeding that keeps coming back. None of these means cancer. Every one of them means examined, not watched. Oral cancer is one of the few cancers a person can see the beginning of in a mirror, and that advantage is wasted by waiting. |
Why it is so hard to stop
Nicotine reaches the brain within seconds of a cigarette and steadily throughout the day with mishri or kharra. Over years, the brain adjusts to expecting it — the same adjustment described on the alcohol pages, in a different chemical.
Then it attaches itself to the day. The first one with tea. After a meal. The one on the way to work. The one after a fight. That is not incidental; it is the reason people who genuinely intend to stop find themselves holding one at 7:40 in the morning without having decided anything.
Withdrawal is real: irritability, restlessness, poor concentration, disturbed sleep, hunger, low mood, and craving that comes in waves. It is at its worst in the first week and largely settles over two to four weeks, though the occasional wave can arrive months later.
Uncomfortable. Not dangerous. Nobody has a seizure from stopping tobacco, and that is worth saying clearly on a page that sits next to the alcohol pages, where the advice is the exact opposite.
Why a psychiatrist is writing this at all
Because tobacco and mental illness sit together far more closely than people expect, and the mental health side of it is where the neglect is worst.
People living with depression, with schizophrenia, with alcohol dependence, smoke considerably more than the general population — and they are the group least often offered help to stop. There is an old assumption in the field that they have enough to deal with and the smoking can wait. It has waited for decades, and it is one of the reasons people with serious mental illness die earlier than everyone else. That is not the illness doing it. It is the tobacco, and the cardiac and respiratory disease behind it.
The other worry I hear constantly: that stopping will worsen the mental illness. In general it does not. Mood after stopping tends to improve rather than deteriorate once the first weeks are past.
One practical point that genuinely matters, and few people are told it: stopping smoking can change how some psychiatric medicines behave in the body. That is not a reason to keep smoking. It is a reason to tell the doctor who prescribes for you that you are stopping, so the treatment can be reviewed rather than surprised.
What actually helps
A fixed quit date
For tobacco, a clean stop generally beats gradual reduction. Cutting down feels safer and is usually where quitting goes to die — the number drifts back up within weeks and nobody notices when.
Pick a date within the next fortnight. Far enough to prepare, near enough that it does not become an idea instead of a plan.
Medicine
There are treatments that reduce craving and blunt withdrawal — some that supply nicotine in a controlled form without the smoke or the tobacco, and some that work in other ways and need a prescription.
I am not going to name them here, for the same reason I do not name them on any page on this site. Which one suits a person depends on how heavy the use is, what else they take, and their other medical conditions. That is a five-minute conversation with a doctor and it roughly doubles what willpower alone achieves.
Someone to check in with
Not lectures. Practical work on the specific moments — the first one of the day, the tea break, the drive, the wedding. Which one is the hard one, and what happens instead.
There is a free national quitline: 1800-11-2356. There is also a government mCessation programme you can join by giving a missed call. Neither costs anything, and for someone who will not walk into a clinic about tobacco, a phone call is a real starting point.
A note on e-cigarettes and vapes
The manufacture, sale, import and advertising of e-cigarettes has been prohibited in India since 2019. Whatever is being said about them elsewhere, they are not a legal route here, and I would not suggest swapping one nicotine dependence for another that arrives without any medical supervision at all.
A story, put together from many
The following is fictional and composite. It is not any one patient.
A woman in her fifties, brought by her son for low mood after her husband’s death. Somewhere in the second consultation, discussing sleep, she mentioned she keeps mishri by the bed.
I asked how many times a day. She counted on her fingers and stopped at fourteen. She had been doing it since she was in her twenties and had never once been asked about it by anyone — not by her family doctor, not by her dentist, not by her children, who knew perfectly well.
When I said the word tobacco she was startled, and then she was annoyed with me, and then she said something I have heard several times since in different words: that if it were really tobacco somebody would have told her by now.
That is the whole problem in one sentence. There is no shame attached to it, so there is no conversation, so there is no information, so there is no stopping.
Her mouth was examined. It was, that time, fine. It is not always fine.
What to do this week
- Actually count, for two days — cigarettes, bidis, or how many times the mishri or kharra goes in. People underestimate by half and the real number is often what moves them.
- Look in the mouth in good light. White patch, red patch, ulcer older than two weeks, or a mouth that opens less than it did — that is a dentist this week, not next month.
- Pick a quit date within a fortnight and tell one person it.
- Ask a doctor about medicine before the date, not after the first bad day.
- Work out which single one of the day is the hard one, and decide now what happens instead of it.
- If you take medicine for a mental health condition, tell that doctor you are stopping, so the treatment can be reviewed.
Frequently Asked Questions.
Is mishri really as harmful as smoking?
It is not a milder version. The harms differ — smoking does more to the lungs, smokeless does more to the mouth — but calling one safe because it is not the other is a false comparison. Both cause dependence and both cause cancer.
I have used it for thirty years. Is there any point stopping now?
Yes. Risk to the heart and blood vessels begins falling within a fairly short time of stopping, and cancer risk falls over years. Later is worse than earlier and considerably better than never.
Will stopping make my depression or anxiety worse?
The first week or two can be irritable and low. Beyond that, mood generally improves rather than worsens. The belief that smoking is treating the anxiety usually turns out to be the relief of the withdrawal between cigarettes, not treatment of anything.
Can I cut down instead of stopping completely?
You can try, and for most people the number drifts back within a few weeks. Tobacco is one of the places where a clean stop on a fixed date works better than tapering — the opposite of the advice for alcohol.
Is it dangerous to stop suddenly?
No. This is one of the clearest differences between tobacco and alcohol, and it is worth knowing if you live in a house where both are used.
Sources
- Global Adult Tobacco Survey (GATS-2) India, 2016-17. Ministry of Health and Family Welfare, Government of India — including the Maharashtra fact sheet.
- World Health Organization. Tobacco and smokeless tobacco fact sheets, and WHO Report on the Global Tobacco Epidemic.
- International Agency for Research on Cancer. Monographs on smokeless tobacco and areca nut.
- National Tobacco Control Programme, Ministry of Health and Family Welfare, Government of India.
- The Prohibition of Electronic Cigarettes Act, 2019, Government of India.
- Indian Psychiatric Society. Clinical Practice Guidelines for the Assessment and Management of Substance Use Disorders.
This article is for education only. It is not a substitute for consultation with a qualified doctor, and it is not a diagnosis or a treatment plan for any individual reader.
If you or someone you know is in distress, free and confidential help is available. Tele-MANAS: 14416 or 1800-891-4416, 24 hours, in Marathi and other Indian languages.
About the author: Dr. Muktesh Daund is a Consultant Psychiatrist and De-addiction Specialist (MBBS, DNB Psychiatry) practising in Nashik, Maharashtra since 2016.