Key Point Gender-specific smoking prevalence varies across the world. Background Worldwide, there are marked differences in smoking prevalence rates between men and women from country to country. For example, in South Africa, the Philippines, China, Iran, and Portugal, smoking prevalence is much lower in women than in men. In contrast, in the United States, Canada, Australia, and Iceland, the prevalence of smoking in men is only slightly higher than that in women. 1 Overall, the prevalence of smoking in men is declining. However, although smoking prevalence in women is declining in some countries, such as the United States, the United Kingdom, Australia, and Canada, in several southern, central, and eastern European countries, the rate of smoking in women is not in decline or is still increasing. 1 Reference 1. Mackay J, Eriksen M, Shafey O. The Tobacco Atlas. Second Ed. American Cancer Society Myriad Editions Limited. Atlanta, Georgia, 2006. Also available online at: http://www.myriadeditions.com/statmap/. 1/Mackay/pp. 98-104, Table A 1/Mackay/pp. 98-104, Table A 1/Mackay/ pp 98-105
Key Point Smoking prevalence rates in some countries are declining. However, mortality associated with smoking is increasing since smoking-related mortality is more closely associated with previous tobacco use rather than with current tobacco use. Background Using data from countries with the longest history of prevalent smoking, Lopez and colleagues constructed a 4-stage model of trends in smoking and subsequent smoking-related mortality. As the model illustrates, peaks in smoking prevalence in the population do not correspond to peaks in smoking-associated mortality, because current mortality rates are more closely related to previous smoking levels. Therefore, although in some regions, such as Western Europe and North America, smoking prevalence in men and women is on the decline, smoking-related mortality is increasing. Similarly, in areas like Asia, Central and South America, and North Africa, where smoking prevalence rates are increasing, the true impact in terms of smoking-related deaths will not be apparent for several decades. 1 In Asia, where one third of the world’s population lives, smoking-related mortality is expected to rise to 4.9 million people annually by 2020 if current smoking trends continue. 2 References 1. Lopez AD, Collishaw NE, Piha T. A descriptive model of the cigarette epidemic in developed countries. Tob Control . 1994;3:242–247. 2. Shafey O, Dolwick S, Guindon GE (eds). Tobacco Control Country Profiles 2003, American Cancer Society; 2003; Atlanta, Georgia. Available at: http://www.who.int/tobacco/global_data/country_profiles/en/. Accessed June 2006. Lopez/p 246/figure A 1/Lopez/p 242/abstract; p 245/col 2/ ¶3; p 246/col 2/ ¶1; figure 2/Shafey/ p 7/col 2/ ¶1
Key Point In some countries, deaths attributable to tobacco account for >25% of total deaths in men aged > 35 years. Background The World Health Organization estimates that in the year 2000, 25% of total deaths in men aged >35 years in most countries in the Northern Hemisphere (including the United States, Canada, Cuba, Israel, Russia and all European nations) were tobacco related. In these countries, >25% of all men died from tobacco-related disorders. Twenty to 25% of women over the age of 35 died from tobacco-related disorders in the United States, Canada, and Cuba. Reference 1. Mackay J, Eriksen M. The Tobacco Atlas . Second Ed. Geneva, Switzerland: World Health Organization; 2006. 2/Mackay/ pp 42, 43. 1/Mackay/ p 36/Figure at bottom; p.37/Figure; p. 40-41/Globe figure 2/Mackay/ pp 42, 43. 1/Mackay/ p 36/Figure at bottom; p.37/Figure; p. 40-41/ Globe figure 2/Mackay/ pp 98-105
Key Point Tobacco puts a considerable burden on estimated annual costs to the economy worldwide. Background The estimated annual costs to the economy attributable to tobacco amounts to billions of US dollars. Examples of these costs range from a high of $184.5 billion in the US (total costs) to $284 million in Venezuela (direct healthcare costs only). Reference 1. Mackay J, Eriksen M, Shafey O. The Tobacco Atlas. Second Ed. American Cancer Society Myriad Editions Limited. Atlanta, Georgia, 2006. Also available online at: http://www.myriadeditions.com/statmap/. 1/Mackay/ 2006, pp 42, 43. 1/Mackay/2006/ pp 42,43 1/Mackay/ pp 98-105
Key Point Tobacco smoke exposes the body to 250 toxic or carcinogenic chemicals. Background Tobacco and tobacco smoke are known to be carcinogenic in humans.Tobacco smoke contains at least 4000 chemicals, at least 250 of which are toxic or carcinogenic. 1 For example, tobacco smoke contains irritants, such as acetone, ammonia, and toluene, found in paint stripper, cleaners, and solvents respectively; toxic heavy metals, such as cadmium, used in car batteries, and arsenic, used in poisons; and carbon monoxide, which is a hazardous component of exhaust fumes. 2 Although it is addictive, the nicotine found in tobacco is not a known carcinogen. 3 All cigarettes are toxic: the US Surgeon General’s report noted that smoking cigarettes with lower yields of tar and nicotine provides no health benefit. 4 References 1. National Toxicology Program. 11th Report on Carcinogens; 2005. Available at: www.cdc.gov/tobacco/ets. 2. Mackay J, Eriksen M. The Tobacco Atlas . Second Ed. Geneva, Switzerland: World Health Organization; 2006. 3. Harvard Health Letter . May 2005. 4. US Department of Health and Human Services. The Health Consequences of Smoking. A Report of the Surgeon General. Atlanta, Georgia: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004. 4/SGR/p. 25/col2/¶2 1/NTP/p. 1/col2/¶4,5 2/Mackay/p34/”Deadly Chemicals” 3/Harvard/p.2/¶3/figure 1/NTP/p. 1/col 2/¶4,5; p. 3/col 1/¶3; p. 4/col 2/¶2; p. 5/col 2/¶4 2/Mackay/ p. 34/ “Deadly Chemicals” 4/SGR /p. 25/ col2/¶2 3/Harvard/ p.2/¶3/ figure
The Tobacco Atlas, 2002 Map 7: Health Inset: Deadly chemicals 100?
Key Point Smoking leads to diminished health status either by contributing to specific disease pathogenesis or by other nonspecific mechanisms. Background The pathological mechanisms of smoking include those specifically linked to the pathogenesis of diseases and those that are less specific. For example, smoking directly exposes lung cells to the potent mutagens and carcinogens which cause genetic changes in lung cells associated with lung cancer development. Smoking causes or contributes to endothelial injury and dysfunction, prothrombotic/fibrinolytic effects, inflammation, and adverse lipid profiles, which lead to cardiovascular disease. Finally, biological processes resulting in airway and alveolar injury and the accelerated decline in respiratory function caused by smoking contribute to the development of COPD. Reference 1. US Department of Health and Human Services. The Health Consequences of Smoking. A Report of the Surgeon General. Atlanta, Georgia: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004. Surgeon General: Lung/p 47/col 2/¶3; IHD/p 365/col1/¶2; p 366/col1/¶3; p367/col 1/¶2; p 368/col 1/¶3, Col 2, ¶4; COPD/p 463/col 2/¶2; p 464/Table 4.13 Surgeon General: p.615/col1/¶1; Lung/ p. 25/col 1/¶2; p 47/col 2/¶3; IHD/ p365/col1/ ¶2; p366/col1/ ¶3; p367/col 1/ ¶2; p 368/col 1/ ¶3, col. 2, ¶4; p. 371/ col 2/¶1 p. 626/col 1/¶2, COPD/ p. 27/col 2/#7; p 463/col 2/¶2; p 464/Table 4.13
Key Point Smoking is causally linked to a host of cardiovascular, respiratory, reproductive, and other conditions, as well as many types of cancer. The top 3 smoking attributable causes of death in the United States are lung cancer, ischemic heart disease, and chronic obstructive pulmonary disease (COPD). Background In 2004, the US Surgeon General published a report on the health effects of active smoking, focusing specifically on the evidence for a causal relationship between smoking and disease and death. According to the research summarized in the report, many serious conditions are caused by smoking, including cardiovascular, respiratory, reproductive, and other conditions, as well as cancer affecting diverse areas and organs of the body. In addition to the widely-known consequences of lung cancer and respiratory disease, smoking has been causally linked to such diverse morbidities as low-bone density, nuclear cataract, bladder cancer, and reduced fertility. 1 Other studies have linked smoking to vascular dementia 2 and peripheral arterial disease. 3 These conditions can affect young and middle-aged smokers and, in general, as a smoker’s age increases, the frequency of smoking-caused diseases rises. 1 References 1. US Department of Health and Human Services. The Health Consequences of Smoking. A Report of the Surgeon General. Atlanta, Ga: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004. 2. Roman GC. Vascular dementia prevention: a risk factor analysis. Cerebrovasc Dis . 2005;20(Suppl 2):91–100. 3. Willigendael EM, Teijink JA, Bartelink ML, et al. Influence of smoking on incidence and prevalence of peripheral arterial disease. J Vasc Surg . 2004;40:1158–1165. 4. Ezzati M, Lopez AD. Regional, disease specific patterns of smoking-attributable mortality in 2000. Tobacco Control . 2004;13:388–395. 1/SGR/p 4-8/Table 1.1; p 860/Table 7.3 2/Roman pg 91 abstract 3/Willigendael pg 1158 abstract 1/SGR/p. iii/¶3,4,5,6; p. 4-8/ Table 1.1 1/SGR/ p. 860/ Table 7.3 2/Roman pg 91 abstract 3/Willigendael pg 1158 abstract 4/Ezzati/ p. 388/ Abstract
Key Point Tobacco smoke exposure in women during pregnancy is associated with serious consequences for infants and children. Background Exposure to tobacco smoke during pregnancy is associated with serious consequences for infants and children. Environmental smoke is associated with a 4-fold increased risk of low-birth weight and an increased risk of miscarriage, stillbirth, and sudden infant death syndrome (SIDS). 1,2 Annually in the United States during the 1990s, 9700–18,600 cases of low-birth weight infants were related to secondhand smoke. 3 In addition, lung function may be impaired, 2 and a possible association with cognitive and developmental syndromes may exist. 1,4 References 1. Fagerström K. The epidemiology of smoking: health consequences and benefits of cessation. Drugs . 2002;62(Suppl 2):1–9. 2. Le Souef PN. Pediatric origins of adult lung diseases. 4. Tobacco related lung diseases begin in childhood. Thorax . 2000;55:1063–1067. 3. Mackay J, Eriksen M. The Tobacco Atlas . Geneva, Switzerland: World Health Organization; 2002. 4. Hellstrom-Lindahl E, Nordberg A. Smoking during pregnancy: a way to transfer the addiction to the next generation? Respiration . 2002;69:289–293. 1/Fagerstrom/p. 5/col 1/¶3. 2.Le Souef/p. 2/¶1-3. 3/Mackay/p 34. 4/Hellstrom/p289/abs 1/ Fagerstrom /p. 5/col 1/¶3. 2.Le Souef/p. 2/¶1-3. 3/Mackay/ p. 34. 1/ Fagerstrom /p. 5/col 1/¶3. 2.Le Souef/p. 2/¶1-3. 4/Hellstrom/p289/abs
Key Point Exposure to secondhand smoke is a serious health hazard; it increases lung cancer risk and worsens pre-existing respiratory diseases, including asthma, COPD, and emphysema. Background Secondhand smoke is a serious health hazard. According to the US Surgeon General’s 2006 report, there is no risk-free level of exposure to secondhand smoke. 1 This recent report, as well as data from the World Health Organization, estimate exposure to secondhand smoke in nonsmokers increases lung cancer risk by 20%–30%. 1,2 In adults, secondhand smoke exposure may also worsen existing lung disease, such as asthma, COPD, and emphysema. 2 Environmental smoking can induce and exacerbate asthma in children and can cause middle ear disease and otitis media. 2 A study in 52 countries showed that secondhand smoke increases risks of nonfatal acute myocardial infarction. The risk was increased in a graded manner, and the effect was most marked in subjects who never smoked and former smokers. The overall attributable risk was 15.4% in subjects who never smoked but are exposed for ≥1 hour per week to secondhand smoke compared with those who never smoked and never were exposed. 3 The 2006 US Surgeon General’s report notes that secondhand smoke exposure increases the risk of heart disease by 25%–30% in nonsmokers. 1 References 1. US Department of Health & Human Services. News release, June 27, 2006; Available at: http://www.hhs.gov/news/press/2006pres/20060627.html. Accessed July 10, 2006. 2. Mackay J, Eriksen M. The Tobacco Atlas . Second Ed. Geneva, Switzerland: World Health Organization; 2006. 3. Teo KK, Ounpuu S, Hawken S, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet . 2006;368:647–658. 1/USDDHS/p 1/¶1 2/Mackay/p 35 3/Teo/p 1/abstract 1/USDDHS/p 1/¶1 2/Mackay/p 35/figure; p 36/col 1 /¶2; p 37/lower figure 3/Teo/p 1/abstract
Key Point Nicotine stimulates dopamine release in areas of the brain which is believed to result in the reward and satisfaction effect associated with smoking. Background After inhalation, nicotine preferentially binds to nicotinic acetylcholinergic (nACh) receptors located in the mesolimbic-dopamine system of the brain within a matter of seconds. Nicotine specifically activates 4 β 2 nicotinic receptors in the Ventral Tegmental Area (VTA) causing an immediate dopamine release at the Nucleus Accumbens (nAcc). 1 The dopamine release is believed to be a key component of the reward circuitry associated with cigarette smoking. 1 Reference 1. Picciotto MR, Zoli M, Changeux J. Use of knock-out mice to determine the molecular basis for the actions of nicotine. Nicotine Tob Res . 1999; Suppl 2:S121-125. 1/Picciotto, p. S121, para 1 1/Picciotto, p. S121, para 1
Key Point Nicotine stimulates dopamine release in areas of the brain which is believed to result in the reward and satisfaction effect associated with smoking. Background Nicotine activates 4 2 nicotinic receptors that are localized to the neuronal bodies and terminal axons of the cells in the ventral tegmental area. This activation thereafter causes dopamine release at the nucleus accumbens, which is believed to result in the short-term reward/satisfaction effect associated with cigarette smoking. Reference Picciotto MR, Zoli M, Changeux J. Use of knock-out mice to determine the molecular basis for the actions of nicotine. Nicotine Tob Res. 1999; Suppl 2:S121-S125. 1/Picciotto, p. S121, para 1 1/Picciotto, p. S121, para 1
Key Point Nicotine may cause up-regulation and desensitization of nicotinic receptors resulting in tolerance. Drops in nicotine levels in combination with up-regualtion and desentization can result in withdrawal and craving. Background Tolerance typically develops after longer-term nicotine use. Tolerance is related to both the up-regulation (increased number) and the desensitization of nicotinic receptors in the VTA that occurs as a result of long-term exposure to nicotine. A drop in nicotine level, in combination with the up-regulation and decreased sensitivity of the nicotinic receptor, can result in withdrawal symptoms and cravings. Smokers have the ability to self regulate nicotine intake by the frequency of cigarette consumption and the intensity of inhalation. In order to maintain a steady nicotine level, smokers generally titrate their smoking to achieve maximal stimulation and avoid symptoms of withdrawal and craving. References 1. Schroeder SA. What to do with a patient who smokes. JAMA. 2005;294:482-487. 2. Jarvis MJ. Why people smoke. BMJ . 2004;328:277-279. 2/Jarvis/ p 277, para 1 1/Schroeder/ p 483, col 2 para 1 1/Schroeder/ p 483, col 2 para 2 2/Jarvis/ p 277, para 1 1/Schroeder/ p 483, col 2 para 1 1/Schroeder/ p 483, col 2 para 2
Key Point Nicotine addiction is a cycle which begins with nicotine binding to receptors in the brain causing the release of dopamine which in turn results in feelings of pleasure and calmness. Background The distribution of nicotine is very rapid. It can reach the brain within 10 to 20 seconds after inhaling cigarette smoke. 1 The binding of nicotine to its relevant receptors results in the release of multiple neurotransmitters, most critically dopamine. The release of dopamine in the nucleus accumbens neurons is thought to play a critical role in the addictive nature of nicotine. This release of dopamine requires binding of nicotine to 4 2 receptors. 1,2 Absorption of cigarette smoke from the lungs is rapid and complete, producing with each inhalation a high concentration of arterial nicotine that reaches the brain within 10 to 16 seconds. Nicotine has a terminal half-life in blood of 2 hours. Smokers therefore experience a pattern of repetitive and transient high blood nicotine concentrations from each cigarette. Nicotine’s activation of acetylcholinergic receptors induces the release of dopamine in the nucleus accumbens. This is similar to the effect produced by other drugs of misuse, such as amphetamines and cocaine. The symptoms of nicotine withdrawal are a major barrier to smoking cessation. Smokers start to experience impairment of mood and performance within hours of their last cigarette. These effects are completely alleviated by smoking a cigarette. Withdrawal symptoms include irritability, restlessness, feeling miserable, impaired concentration, and increased appetite, as well as craving for cigarettes. Cravings, sometimes intense, can persist for many months. References Jarvis MJ. Why people smoke. BMJ . 2004;328:277-279. Picciotto MR, Zoli M, Changeux J. Use of knock-out mice to determine the molecular basis for the actions of nicotine. Nicotine Tob Res. 1999; Suppl 2:S121-S125. 1/Jarvis/ p 278, para 1 1/Jarvis/ p 278, para 1 1/Jarvis/ p 278, para 1 1/Jarvis/ p 278, para 2 1/Jarvis/ p 277, para 5 1/Jarvis/ p 278, para 1, 2, 3 1/Jarvis/ p 277, para 5 2/Picciotto, p. S121, para 1 2/Picciotto, p. S121, para 1
Key Point Quitting smoking reduces the risk of cardiovascular events. Background Quitting smoking substantially reduces the risk of all-cause mortality in individuals with CHD. A 2003 review of 9 electronic databases containing data from 1966 to 2003 for prospective cohort studies of patients with CHD, found that those who quit smoking had a 36% reduction in odds of all-cause mortality. 1 A reduction in risk of cardiac events is evident even among those who recently quit. In a German study of 967 patients aged 30–70 years who already had experienced an acute coronary event, Twardella et al found that the odds ratio (OR) for subsequent cardiovascular events decreased according to smoking status. Based on serum cotinine levels, patients were classified as never smokers, former smokers, and current smokers. Patients who said they smoked but who were negative for cotinine were classified as recent quitters. Assigning an OR of 1.00 for current smokers, the OR for recent quitters was 0.71, 0.64 for former smokers, and 0.44 for those who never smoked. 2 References 1. Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA . 2003;290:86–97. 2. Twardella D, Kupper-Nybelen J, Rothenbacher D, Hahmann H, Wusten B, Brenner H. Short-term benefit of smoking cessation in patients with coronary heart disease: estimates based on self-reported smoking data and serum cotinine measurements. Eur Heart J . 2004;25:2101–2108. 1/Critchley/ p 86/abstract 2/Twardella/ p. 2106/ Table 4; p 2107/col 2/¶2 2/Twardella/ p. 2101/ abstract; p. 2102/ col 1/¶5; p. 2106/ Table 4 1/Critchley/ p 86/ abstract/p87 methods
THE ROLE OF NGOs IN TOBACCO CONTROL Prof. Dr Lekhraj Rampal MBBS, MPH, DRPH, FRSH, FAMM Deputy Chairman Malaysian Health Promotian Board Chairman, Action on Smoking and Health Committee, MMA 1993, 1996 -2009 Chairman, International Quit smoking and Win – MALAYSIA 1998, 2000, 2002, 2004,2006 Chairman, National Organizing Committee- World No Tobacco Day – Malaysia1993, 2002, 2004,2006 9th August 2009 RAMPAL
Two Hundred and Fifty Million ( 250,000,000) children alive today eventually will die from smoking
- ABOUT HALF A BILLION ( 500,000,000)
PEOPLE ALIVE TODAY WILL DIE FROM SMOKING
9th August 2009 RAMPAL
Gender-Specific Smoking Prevalence Across the World 1. Mackay J, et al. The Tobacco Atlas . Second Ed. American Cancer Society Myriad Editions Limited, Atlanta, Georgia, 2006. Also available online at: http://www.myriadeditions.com/statmap/. US 24% 19% Men Women Australia 19% 16% Belarus 53% 7% Brazil 22% 14% Canada 22% 17% Chile 48% 37% China 67% 2% Egypt 45% 12% France 30% 21% Iceland 25% 20% Mexico 13% 5% Iran 22% 2% Kenya 21% 1% Sweden 17% 18% Philippines 41% 8% Portugal 33% 10% South Africa 23% 8% India 47% 17% Russian Fed 60% 16% Italy 33% 17% Spain 39% 25% Germany 37% 28%
Four Stages of the Tobacco Epidemic: Mortality Is Increasing in Many Countries 1 % female deaths 0
If current smoking patterns continue, deaths from smoking in Asia—home to a third of the world’s population—are expected to increase by 2020 to 4.9 million annually. 2 Percentage of smokers among adults Percentage of deaths caused by smoking
Western Europe, UK
STAGE 1 STAGE 2 STAGE 3 STAGE 4 70 60 50 40 30 20 10 0 70 60 50 40 30 20 10 0 80 90 100 40 30 20 10 % male deaths % male smokers % female smokers Years 1. Lopez AD, et al. Tobacco Control . 1994;3:242-247. 2. Shafey O, et al (eds). Tobacco Control Country Profiles 2003, American Cancer Society; 2003; Atlanta, Georgia. Available at: http://www.who.int/tobacco/global_data/country_profiles/en/. Accessed June 2006.
As smoking rate decline in the wealthy nations, the tobacco pandemic has moved to the developing countries
80 % of them live in low and middle income countries
9th August 2009 RAMPAL
Every day , THOUSANDS of young people around the world are trying their first cigarette and 80,000 – 100,000 are becoming regular smokers often precipitating a lifetime of addiction and untimely death. 9th August 2009 RAMPAL
Annual Deaths Attributable to Tobacco: Worldwide Estimates Canada >25% Australia 20%-24% UK >25% Germany >25% China & Taiwan 10%-14% Brazil 15%-19% % of Total Deaths Attributable to Tobacco* *Regional estimates in 2000 in men aged >35 years. 1. Mackay J, Eriksen M. The Tobacco Atlas. Second Ed. World Health Organization; 2006. US >25% Mexico 15%-19% Argentina 15%-19% Spain >25% Russian Federation >25% Sweden >25% Turkey >25% 9th August 2009 RAMPAL
Fig 13:“Youth should be inculcated in a “ Calture without Tobacco”- Chairman ASH IQSW 2000 9th August 2009 RAMPAL
Tobacco must be seen as a drug, not as a more agricultural product. Tobacco is a dangerous product and hazardous to health and it is lethal. 9th August 2009 RAMPAL
"Tobacco: deadly in any form or disguise," focusing on the fact that all tobacco products are addictive, harmful and can cause death, regardless of the form, packaging, or name under which they are presented to the public”.
There is a need for strict regulation and encourage its implementation.
Smokeless tobacco products, such as snus and snuff are being marketed heavily to specific target groups:
women (in cultures where it is not socially acceptable for them to smoke); young people (presented with flavoured and milder-tasting "starter" products); or to smokers (as an alternative in smoke-free environments).
At the same time, forms of non-cigarette smoking, such as waterpipes, also known as "shishas", "narghiles" or "hubble-bubbles", are gaining wider acceptance around the world, especially among young people in cafés and on college campuses.
"The evidence is clear, there is no safe level of exposure to second-hand tobacco smoke,"
I urge all countries that have not yet done so to take this immediate and important step to protect the health of all by passing laws requiring all indoor workplaces and public places to be 100% smoke-free ."
WHO Director-General Dr Margaret Chan. 9th August 2009 RAMPAL
The costs of second-hand smoke are not limited to the burden of disease.
Exposure also imposes economic costs on individuals, businesses and society as a whole.
These include primarily direct and indirect medical costs, but also productivity losses.
In addition, workplaces where smoking is permitted incur higher renovation and cleaning costs, and increased risk of fire, and may experience higher insurance premiums.
9th August 2009 RAMPAL
RM 4.5 billion per year (US$1.3 BILLION/PER YEAR) 1 st JUNE 2007 9th August 2009 RAMPAL
Estimated Annual Costs Attributable to Tobacco Canada $12.9 Australia $14.2 France $16.4 Germany $24.4 China $4.3 US $184.5 Estimated Costs to the Economy Attributable to Tobacco (US $ Billions) UK $2.3 Norway $1.62 1. Mackay J, et al. The Tobacco Atlas. Second Ed. American Cancer Society Myriad Editions Limited. Atlanta, Georgia, 2006. Also available online at: http://www.myriadeditions.com/statmap/. Venezuela $.284 Total Costs Direct Healthcare Costs 9th August 2009 RAMPAL
Smoking cigarettes with lower tar and nicotine provides no health benefit 4
1. National Toxicology Program. 11th Report on Carcinogens; 2005. Available at: http://ntp-server.niehs.nih.gov. 2. Mackay J, Eriksen M. The Tobacco Atlas . World Health Organization; 2006. 3. Harvard Health Letter . May 2005. 4. Surgeon General’s Report. The Health Consequences of Smoking ; 2004. Chemical in Tobacco Smoke 2 Also Found In… Acetone Paint stripper Butane Lighter fluid Arsenic Ant poison Cadmium Car batteries Carbon monoxide Car exhaust fumes Toluene Industrial solvent
Tobacco is the only freely available product which, when used as intended by the manufacturer, kills half of its dedicated users. 9th August 2009 RAMPAL
Mechanisms of Action: How Smoking Causes Disease
Direct respiratory cell exposure to potent mutagens and carcinogens in tobacco smoke
Ischemic heart disease
Toxic products in the bloodstream create a
Leads to endothelial injury and dysfunction, thrombosis, inflammation, and adverse lipid profiles
Chronic Obstructive Pulmonary Disease (COPD)
Accelerated decline in respiratory function
1. Surgeon General’s Report. The Health Consequences of Smoking ; 2004.
Smoking: Leading Preventable Cause of Disease and Death 1 Top 3 Smoking-Attributable Causes of Death in US #1 Lung cancer #2 Ischemic heart disease #3 COPD Cancer Lung (#1)* Leukemia (AML, ALL, CLL) 2-4 Oral cavity/pharynx Laryngeal Esophageal Stomach Pancreatic Kidney Bladder Cervical Cardiovascular Ischemic heart disease (#2)* Stroke – Vascular dementia 5 Peripheral vascular disease 6 Abdominal aortic aneurysm Respiratory COPD (#3)* Pneumonia Poor asthma control Reproductive Low-birth weight Pregnancy complications Reduced fertility Sudden Infant Death Syndrome Other Adverse surgical outcomes/wound healing Hip fractures Low-bone density Cataract Peptic ulcer disease † *Top 3 smoking-attributable causes of death. † In patients who are Helicobacter pylori positive. AML = Acute myeloid leukemia; ALL = acute lymphocytic leukemia; CLL = chronic lymphocytic leukemia; COPD = chronic obstructive pulmonary disease; SIDS = sudden infant death syndrome. 1. Surgeon General’s Report. The Health Consequences of Smoking ; 2004. 2. Sandler DP, et al. J Natl Cancer Inst . 1993;85(24):1994-2003. 3. Crane MM, et al. Cancer Epidemiol Biomarkers Prev . 1996;5(8):639-644. 4. Miligi L, et al. Am J Ind Med . 1999;36(1):60-69. 5. Roman GC. Cerebrovasc Dis . 2005;20(Suppl 2):91-100. 6. Willigendael EM, et al. J Vasc Surg . 2004;40:1158-1165. 9th August 2009 RAMPAL
Increased risk of miscarriage, stillbirth, sudden infant death syndrome (SIDS); eg
4-fold risk1: eg, 9700–18,600 cases related to secondhand smoke annually in US* 3
Impaired infant lung function 2
Possible association with cognitive and developmental syndromes 1,4
*1990s. 1. Fagerström K. Drugs . 2002;62(Suppl 2):1–9. 2. Le Souef PN. Thorax . 2000;55:1063–1067. 3. Mackay J, et al. The Tobacco Atlas. World Health Organization; 2002. 4. Hellstrom-Lindahl E, et al. Respiration. 2002;69:289-293. 9th August 2009 RAMPAL
For every person who dies from tobacco use, another 20 suffer with at least one serious tobacco-related illness. Half of all long-term smokers die prematurely from smoking-related causes. Until recently this epidemic of chronic disease and premature deaths mainly affected the rich countries. It is now rapidly shifting to the developing world. 9th August 2009 RAMPAL
Believed to cause and worsen diseases such as asthma, COPD, and emphysema 2
Increases risk for developing heart disease by 25%–30% 1
Increases risk of nonfatal acute myocardial infarction in a graded manner 3
1. News release, June 27, 2006; US Department of Health & Human Services. Available at: http://www.hhs.gov/news/press/2006pres/20060627.html. 2. Mackay J, et al. The Tobacco Atlas. World Health Organization; 2002. 3. Teo KK, et al. Lancet. 2006;368:647-658. 9th August 2009 RAMPAL
PREVALEVE OF SMOKING IN MALAYSIA 9th August 2009 RAMPAL
Prevalence of Smoking among Malaysians Estimated: ~ 3 million smokers in Malaysia (2006) 9th August 2009 RAMPAL 1996 2004 2006 NHMS2 UPM NHMS3 ( > 18 yrs) ( > 18 yrs) ( > 18 yrs) Overall 24.8% 23.2% 21.5% Male 49.2% 47.2 46.4% Female 3.5% 2.7% 1.6% Malay 27.9% 28.9 % 24% Chinese 19.2% 18.7% 16.2% Indian 16.2% 16.8% 13.7% Others 32.4% 22.5% 23.8%
Table III: Prevalence of ever and current smokers by sex and ethnicity 2004 9th August 2009 RAMPAL Ethnicity Sex Prevalence of Ever Smokers % (SE %) Prevalence of Current Smokers % (SE %) All Races Male Female Both 59.3 (0.7) 4.8 (0.3) 32.0 (0.5 ) 47.2 (0.7) 2.7 (0.2) 24.9 (0.4) Malay Male Female Both 69.8 (0.8) 4.6 (0.3) 37.0 (0.6) 55.6 (0.9) 2.6 (0.2) 28.9 (0.6 ) Chinese Male Female Both 45.2 (1.6) 5.0 (0.6) 25.3 (1.0) 34.1 (1.5) 3.0 (0.4) 18.7 (0.9) Indian Male Female Both 41.1 (2.2) 1.1 (0.3) 21.1 (1.3 ) 33.4 (2.1) 0.5 (0.2) 16.8 (1.2) Others Male Female Both 55.4 (10.4) 5.1 (2.0) 27.5 (4.7 ) 46.1 (9.4) 3.5 (1.6) 22.5 (4.4) Bumiputra Sarawak Male Female Both 61.2 (3.6) 10.7 (1.9) 35.8 (2.3 ) 50.9 (3.2) 5.2 (1.4) 27.9 (2.0) Bumiputra Sabah Male Female Both 57.5 (2.4) 5.5 (1.0) 32.0 (1.6 ) 50.2 (2.2) 2.6 (0.6) 26.8 (1.6)
NHMS3 - Adult Smoking Prevalence 9th August 2009 RAMPAL Ever Smoker Current Smoker Ex-Smoker Overall 27.0% 21.5% (2.73M) 5.4% Male 57.6% 46.4% (2.61M) 11.0% Female 2.5% 1.6% (0.12M) 0.9% Urban 24.1% 18.9% (1.56 M) 5.0% Rural 32.3% 26.2% (1.17 M) 6.0%
NHMS3 - Adolescent Smoking Prevalence ( 13 to <18 years) 9th August 2009 RAMPAL Overall Boys Girls Ever smokers - Young people who have ever smoked a cigarette (even 1puff) 14.7% (180,328) 26.2% (162,438) 3.0% (17,891) Current smokers - Young people who smoke on at least one day in the last 30 days preceding the survey 8.7% (107,154) 16.6% (103,240) 0.7% (3,914) Frequent/ established smokers Young people who have smoked on at least 20 of the 30days preceding survey 3.3% (40,172) 6.4% (39,083) 0.18% (1,089) Experimental smokers - Young people who have smoked < 20days for the past 30 days & not smoked for last 7 days 1.1% 1.9% 0.2% Triers - Young people who ever tried to smoke but stopped after only one (1) cigarette or after a few puffs 5.2% 8.3% 2%
10 Principal Causes of Deaths in MOH Hospitals, 2006 9th August 2009 RAMPAL Septicaemia 16.87% Heart Diseases & Diseases of Pulmonary Circulation 15.70% Malignant Neoplasm 10.59% Cerebrovascular Diseases 8.49% Pneumonia 5.81% Accidents 5.59% Diseases of the Digestive Systems 4.47% Certain Conditions Originating in the Perinatal Period 4.20% Nephritis, Nephrotic Syndrome & Nephrosis 3.83% Ill-defined conditions 3.03%
Total Treatment Cost for 3 Smoking Related Diseases/ Year (RM - million ) Syed Aljunid, 2005 9th August 2009 RAMPAL Mean Min Max Patient 949.8 682.3 1730.6 Provider 1975.0 925.0 3257.7 Total 2924.8 1607.3 4988.3 % of GDP 0.74 0.41 1.27 % of NHE 16.49 9.06 28.12 % MOH budget 26.14 12.24 43.11
Factors Influencing Tobacco Use 9th August 2009 RAMPAL
1. Tobacco industry marketing and advertising 2. Profit margin/ Sales are legal even though it kills half of its user 3. Nicotine Addiction 4. Low Tobacco Tax 5. Peer smoking status and influence 6. Parental smoking status 7. Smoking environment in Workplace and house 8. Greed and Corruption 9. Smuggling of tobacco products 9th August 2009 RAMPAL
Nicotine activates 4 2 nicotinic receptors in the ventral tegmental area resulting in dopamine release at the nucleus accumbens. This may result in the short-term reward/satisfaction associated with cigarette smoking.
D Ventral Tegmental Area Nucleus Accumbens Adapted from Picciotto MR, et al. Nicotine and Tob Res . 1999: Suppl 2:S121-S125. D 4 2 Nicotinic Receptor Nicotine Dopamine Reward D D D Axon
Nicotine May Cause Up-Regulation and Desensitization of Receptors Resulting in Tolerance
Tolerance typically develops after long-term nicotine use 1
Tolerance is related to both the up-regulation (increased number) and the desensitization of nicotine receptors in the VTA 1
A drop in nicotine level, in combination with the up-regulation and decreased sensitivity of the nicotinic receptor, can result in withdrawal symptoms and cravings 1
Smokers have the ability to self regulate nicotine intake by the frequency of cigarette consumption and the intensity of inhalation 1
In order to maintain a steady nicotine level, smokers generally titrate their smoking to achieve maximal stimulation and avoid symptoms of withdrawal and craving 2
1. Schroeder SA. JAMA. 2005;294:482-487. 2. Jarvis MJ. BMJ. 2004; 328:277-279.
large numbers of people will continue to smoke because they cant give it up. If they could they would do so. They can no longer be said to make an adult choice.” ( British American Tobacco 1980)
Nicotine is the addictive agent in cigarettes ( Brown & Williamson memo from A.J.Mellman 1983)
9th August 2009 RAMPAL
SMOKING IN UTERO INCREASES RISK OF LATER ADDICTION ARNOLD MANN NIDA, 2004: 19 (4) 9th August 2009 RAMPAL
Patrick Zickler NIDA 2004; 19 (2) SMOKING MAY BE MORE ADDICTIVE IF IT IS INITIATED DURING ADOLESCENCE, AND EARLY EXPOSURE MAY HEIGHTEN RESPONSE TO OTHER ADDICTIVE DRUGS. MALES AND FEMALES MAY DIFFER IN THEIR SUSCEPTIBILITY TO THESE EFFECTS 9th August 2009 RAMPAL
TOBACCO PRICE WAR - Decline in tobacco price ???Answer: Increase Taxes to such an extent that tobacco companies don’t think of reducing their price again. Use the money for Tobacco control activities and for Victims of Tobacco Use 9th August 2009 RAMPAL
1998 : International Quit Smoking and Win competition and National Art competition "Growing up without Tobacco" More than 945 people from all parts of Malaysia participated. This was the first time such a large number agreed to give up smoking for at least one month. The art competition was also a big success.
2000 : ASH, MMA and the Public Health Society jointly with the Ministry of Health organised the International Quit Smoking and Win competition. More than 1,155 people from all parts of Malaysia participated. ASH, MMA also organized a National Art Competition. The art competition was also a big success and several prizes were given out for both the events.
In 2002, Malaysian Government decided to establish a Health Promotion Foundation using Taxes from Tobacco and Alcohol (Sin Tax) .
1992-2003: Most federal and state departments have declared the work place as smoke free. All Government Universities and most Institutions of Higher Learning declared Smoke Free carried out smoking control activities. Smoking control activities in work place, has in last two years also significantly increased and making an impact not only in the government but also private sector. Many private firms and factories are increasingly making their workplace a smoke free zone and organising various smoking control activities.
9th August 2009 RAMPAL
ASH, MMA SUBMITS MEMORENDAM TO GOVERNMENT TO BAN SMOKING IN PUBLIC PLACES 9th August 2009 RAMPAL
(Chairman,Organizing Committee IQSW Malaysia, and Chairman, ASH,MMA)
Tan Sri Dato Dr Abdul Majid,
( Deputy President, National Heart Foundation)
Dato Farid, President National Cancer Council
Dr Sallehudin (Representive, Ministry of Health Malaysia
Dato Dr P Krishnan, President Malaysian Medical Association
9th August 2009 RAMPAL
The International Quit Smoking and Win is an Global Joint event involving 75 countries and we expect 500,000 to one million participants to give up smoking for at least one month it also helps to inform the general public about harmful effects on health by tobacco consumption. 9th August 2009 RAMPAL
ROLE - ADVOCATIVE Tobacco Advertisment Issue brought up by Dr Lekhraj Rampal, Chairman, ASH ,MMA’ and Minister Agrees to bring up the Issue of Tobacco Advertisment to Cabinet 9th August 2009 RAMPAL
ASH,MMA WRITES TO MINISTRY OF HEALTH TO HAVE WARNING MESSAGES ON CIG. PACKETS
9th August 2009 RAMPAL
IMPACT Malaysia enacted the control of Tobacco Product Regulations 1993 under the Food Act 1983 to discourage smoking in the country. A number of provisions are made in the Regulations to curb smoking. This includes areas such as cigarette accessibility to children, health warning messages and cigarette advertising. One of the programs intended to discourage smoking is the anti-tobacco media campaign. 9th August 2009 RAMPAL
Fig 14: President Malaysian Medical Association and Chairman ASH Slam Tobacco Firms Over Warning Labels 9th August 2009 RAMPAL
Health professionals such as physicians, nurses, midwives, pharmacists, dentists, physiologists, chiropractors, and other health-related professionals have an enormous potential to play a key role in battling the tobacco epidemic.
They have several roles in common and that work in unison, where one role does not substitute for another .
Tobacco control measures must be based on facts and evidence.
Research in less programme and policy implementation and evaluation should be encouraged as well.
You have a duty to create awareness and educate funding and research agencies about tobacco consumption’s impact on all aspects of individual, community and social health, so that adequate funding resources for research in addressing this worldwide epidemic.
WINNERS OF COMPETITION BEING GIVEN PRIZES 9th August 2009 RAMPAL
USING ART AND CULTURE IN TOBACCO CONTROL 9th August 2009 RAMPAL
NATIONAL ART COMPETITION 2005 ASH, MMA THEME: HARMFUL EFFECTS OF TOBACCO AND TOBACCO PRODUCTS – START A HEALTHY LIFESTYLE WITHOUT TOBACCO ORGANIZED BY MMA WITH THE ASSISTANCE OF MINISTRY OF EDUCATION, HEALTH AND PRIVATE SECTOR 9th August 2009 RAMPAL
NATIONAL ART POSTER COMPETITION - 2005 ORGANIZED BY ASH, MMA
1300 ENTRIES FROM ALL STATES IN MALAYSIA PARTICIPATED