Smokeless tobacco dependence managed by Phosphorous in LM potency - A case report

INTRODUCTION

Tobacco dependence is defined by the national tobacco control programme, India, as a ‘cluster of behavioural, cognitive and physiological phenomena that develop after repeated tobacco use and include a strong desire to use tobacco, difficulties in controlling its use and persistence in its use despite its harmful consequences’.^[1] The international classification of diseases (ICD) 11 defines nicotine dependence as a disorder of regulation of nicotine use arising from repeated or continuous use of nicotine. The characteristic feature is a strong internal drive to use nicotine, which is manifested by the impaired ability to control use, increasing priority given to use over other activities and persistence of use despite harm or negative consequences. These experiences are often accompanied by a subjective sensation of urge or craving to use nicotine. The physiological features of dependence may also be present, including tolerance to the effects of nicotine, withdrawal symptoms following cessation or reduction in use of nicotine, or repeated use of nicotine or pharmacologically similar substances to prevent or alleviate withdrawal symptoms. The features of dependence are usually evident over a period of at least 12 months.^[2]

Various forms of smokeless tobacco (SLT) consumed in India include betel quid chewing, mishri, khaini, gutka, snuff, tambakoo, mawa, chap and as an ingredient in pan masala.^[3-5] Several SLT products, such as madhu chhap, hans chhap, miraj and gutkha, are commonly available in the Indian market.^[6,7] Approximately 29.6% of men, 12.8% of women and 21.4% of the entire adult population use SLT in India currently. Among regular users, the average age at initiation is 18.8 years.^[8] The disease burden of SLT is approximately 4.38 million annual national disability-adjusted life years, 4.3 million years of life lost and over 171 thousand deaths due to oral and stomach cancer and ischemic heart disease.^[9]

Chewing tobacco and snuff are similar SLT products that are stored in the mouth and spit out after use.^[10] Absorption takes place through the buccal mucosa.^[11] Typically, a dose of SLT comprises 3.6–4.5 mg of nicotine. The brain starts to respond to this nicotine content within 30 min of intake; the effect lasts for up to 60 min after use.^[10]

The use of chewing tobacco is associated with numerous dental, periodontal, and oral soft-tissue problems, including loss of periodontal attachment, tooth staining, halitosis, and leukoplakia.^[10] SLT is composed of more than 30 carcinogens, including nitrosamines, nitrates, and nitrites, as well as heavy metals.^[12,13] More than 90% of the carcinoma of the oral cavity is due to tobacco use.^[14]

The Fagerstrom test for nicotine dependence-smokeless tobacco (FTND-ST) is a standard scale used for assessing the intensity of SLT addiction.^[15]

More than half of Indian tobacco users wish to quit, but the addictive nature of tobacco poses a challenge to this.^[14] First-line drugs such as bupropion and varenicline are the non-nicotine replacement therapy approved for the cessation of tobacco use by the Food and Drug Administration in India. However, both these drugs are known to produce adverse events, including psychological problems.^[5,16] This throws light on the necessity of an appropriate pharmacological aid with minimal to no side effects for the cessation of tobacco.

Several alternative therapies are included, such as acupuncture, pranayama-like breathing exercises, yoga, meditation, and the use of traditional products like Avena sativa, calamus, herbal tea, and black pepper.^[14] The most effective and recognised way of stopping tobacco use is by incorporating both behavioural and pharmacological interventions.^[17] Homoeopathic medicines such as Arsenicum album, Nux vomica, Plantago, Calcarea phosphorica, Camphora, Cinchona, Coca, Kola, Olibanum sacrum, Phosphorus, Spigelia, Staphysagria, Tabacum, and Tamarind are mentioned in the literature for their usefulness in reducing the craving for tobacco.^[18] A study by Deepak shows sulphur as the most frequently indicated remedy for tobacco dependence. Nux vom, Calc carb, Ars alb, Nat mur, Staph, Ignatia, Caladium and Phosphorus were the other indicated remedies.^[19] The available literature in homoeopathy for tobacco dependence focuses on tobacco smoking.^[5,14,20] Studies related to the use of homoeopathic medicines for SLT dependence are scarce. We present a case report wherein homoeopathic treatment helped wean a patient off the use of SLT.

CASE REPORT

Therapeutic intervention

Phosphorus was chosen as the individualised homoeopathic medicine based upon the totality of the patient including the lean body with fair complexion, friendly behaviour, cold cravings and tobacco desire. The repertorisation chart is provided in Figure 1.

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Figure 1:

Repertorisation chart.

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Follow-up and outcomes

Follow-up and interventions are shown in Table 1. Change in scale score is shown in Figure 2. The Modified Naranjo criteria for this case are provided in Table 2. No adverse reactions were reported in this case.

Table 1: Follow-ups and interventions.

Month	Observation	FTND-ST score	Intervention
February 2023 (Baseline)	3–4 packets (15 g/packet) of chapped tobacco (Hans) daily	6	Phos 0/1 aqua -1 spoon BD in half cup
March 2023	Daytime usage of Hans has reduced. Taking 2–3 packets in the afternoon. Appetite increased	5	Phos 0/1 aqua 1 spoon BD in half cup Advised to take pepper powder immediately after use of Hans Suggested to watch the adverse effect of tobacco videos and images.
April 2023	Hans usage reduced (2 packets/day) appetite reduced Mentally, he is calm now	4	Phosphorus 0/1 in aqua 1 spoon BD (continuing pepper powder)
May 2023	Mentally calm. Tried to abstain from Hans for 24 h, but next day frequency increased (1–2 packets times a day). Again, tried for 24 h and frequency increased again	5	Phosphorus 0/2 in aqua 1 spoon BD (continuing pepper powder)
June 2023	Hans’ usage increased (2 packets, 3–4 times a day) due to stress about his girlfriend and family land dispute. Sleeplessness	5	Phosphorus 0/3 in aqua 1 spoon BD (continuing pepper powder)
July 2023	Better than before Reduced Hans’ usage to 1 pack in 2 days. Now using pepper mixed with Hans Sleep is good	3	Phosphorus 0/3 in aqua 1 spoon BD
August 2023	Decreased usage (1 pack in 2–3 days) trying black pepper mixed in Hans	3	Phosphorus 0/3 in aqua 1 spoon BD
September 2023	Decreased Hans’ usage (1 pack in 2–3 days with decreased frequency). Presented with abdominal pain, vomiting and abdominal discomfort due to outside food	3	Phosphorus 0/3 in aqua 1 spoon BD Ars alb 1M 3 doses (1 dose+2 doses SOS)
October 2023	Hans’ usage reduced (1 pack per week)	1	Phosphorus 0/3 in aqua 1 spoon BD
November 2023	Hans’ usage reduced Sleep disturbed Fluent watery coryza	0	Phosphorus 0/3 in aqua 1 spoon BD Allium cepa 30 in pills TDS
December 2023	Status quo	0	Phosphorus 0/3 in aqua 1 spoon BD
January 2024	Usage increased for 3 days in between during Stress related to the job Mentally down. Once while checking at forest, he got caught by police in front of his friends and felt ashamed about it.	1	Phosphorus 0/4 in aqua 1 spoon BD
February 2024 (1 year)	1 pack in a week One full day without Hans, only with pepper. General improvement	0	Phosphorus 0/4 in aqua 1 spoon BD
March 2024	Consumed Hans only during examination that too mixed with pepper. Not using otherwise	0	Phosphorus 0/4 in aqua 1 spoon BD
April 2024	Stress over his girlfriend Continuing his course but cannot focus on studies Now using only pepper in the Hans packet	0	Phosphorus 0/4 in aqua 1 spoon BD
May 2024	Concentration in studies improving Fully stopped using Hans for 1 week.	0	Phosphorus 0/4 in aqua 1 spoon BD
June 2024	Father was hospitalised with myocardial infarction. Patient was severely stressed, but managed without taking Hans.	0	Phosphorus 0/4 in aqua 1 spoon BD
July 2024	Father discharged under semi-ventilator at home, stress persisting, wants to use Hans, but has avoided so far	0	Phosphorus 0/4 in aqua 1 spoon BD
August 2024 (1 year, 6 months)	No use of Hans	0	Phosphorus 0/4 in aqua 1 spoon BD

FTND-ST: Fagerstrom test for nicotine dependence-smokeless tobacco, BD: Bis in die (twice a day), SOS: Si opus sit (as required), TDS: Ter die sumendum (thrice a day)

Table 2: Modified Naranjo criteria.

Criteria	Yes	No	Not sure or N/A	Score for this case
1. Was there an improvement in the main symptom or condition for which the homeopathic medicine was prescribed?	+2	−1	0	+2
2. Did the clinical improvement occur within a plausible timeframe relative to the drug intake?	+1	−2	0	+1
3. Was there a homeopathic aggravation of symptoms?	+1	0	0	0
4. Did the effect encompass more than the main symptom or condition (i.e., were other symptoms, not related to the main presenting complaint, improved or changed)?	+1	0	0	+1
5. Did overall well-being improve? (Suggest using a validated scale or mention changes in physical, emotional and behavioural elements)	+1	0	0	+1
6 (A) Direction of cure: Did some symptoms improve in the opposite order of the development of symptoms of the disease?	+1	0	0	0
6 (B) Direction of cure: Did at least one of the following aspects apply to the order of improvement of symptoms: • From organs of more importance to those of less importance • From deeper to more superficial aspects of the individual • From the top downwards	+1	0	0	0
7. Did ‘old symptoms’ (defined as non-seasonal and non-cyclical symptoms that were previously thought to have resolved) reappear temporarily during the course of improvement?	+1	0	0	0
8. Are there alternative causes (other than the medicine) that – with a high probability – could have produced the improvement? (Consider known course of disease, other forms of treatment and other clinically relevant interventions)	−3	+1	0	0
9. Was the health improvement confirmed by any objective evidence*? (e.g., investigations, clinical examination, etc.)	+2	0	0	+2
10. Did repeat dosing, if conducted, create similar clinical improvement?	+1	0	0	+1
Total score (range−3–13), N/A: Not applicable				8

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Figure 2:

Change in Fagerstrom test for nicotine dependence-smokeless tobacco (FTND-ST) score during follow-ups.

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DISCUSSION

Nicotine addiction, in all its forms, is a significant and increasing public health hazard. De-addiction is made difficult by the presence of neuronal nicotinic acetylcholine receptors, which regulate both the rewarding and aversive effects of nicotine.^[11,21]

Literature suggests the role of herbal products like black pepper and lime in reducing the craving for tobacco smoking.^[22] In this case, the patient was asked to mix pepper powder with the SLT product to reduce the reward and to create aversion as a method to reduce the SLT dependence.

The current case demonstrates the benefits of the homoeopathic remedy Phosphorus in SLT dependence. The frequent repetition, minimal aggravation and the use of minimal material doses associated with LM potencies contributed to a unique therapeutic profile that enables quicker recovery.^[23] The LM potency was used in this case to allow frequent repetition; this was to combat the patient’s frequent cravings for SLT. The use of LM potency was found to be safe as well.

In dependent users, SLT abstinence is typically accompanied by an urge to consume the same, restlessness, hunger, irritability and other adverse mood changes.^[24,25] Other less frequent but occasionally severe tobacco withdrawal symptoms include insomnia, mouth ulcers and constipation.^[26-28] None of these symptoms occurred in the present case; this raises the possibility that using homoeopathic treatment, especially in the LM potency, could help prevent withdrawal symptoms.

CONCLUSION

The current case highlights the effectiveness of the indicated individualised homoeopathic medicine Phosphorus in LM potency, based on susceptibility, in the treatment of SLT dependence, and suggests future research in this area. Controlled studies are necessary to explore the effectiveness and efficacy of homeopathic medicines in this most-needed area.