The document discusses the role of non-governmental organizations (NGOs) in tobacco control. It notes that tobacco kills over 4 million people per year worldwide and discusses factors that influence tobacco use. It emphasizes that NGOs have an important role to play in tobacco control efforts through advocacy, education, and policy work to reduce tobacco use and its health impacts.

1. 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

2. CONTENTS GLOBAL IMPACT OF TOBACCO USE ON HEALTH FACTOR INFLUENCING (ASSOCIATED WITH) TOBACCO USE ROLE OF NGOs IN TOBACCO CONTROL 9th August 2009 RAMPAL

3. UNDERSTANDING AND COMBATING THE PROBLEM 9th August 2009 RAMPAL

4. THE GLOBAL IMPACT OF SMOKING ON HEALTH Smoking is the major preventable cause of disease in the world. Tobacco kills It causes more than four million (4,000,000) deaths per year (WHO ) 9th August 2009 RAMPAL

5. The 5 million deaths per year from tobacco smoking are not the result of liberty and free choice by adult and responsible consumers (60 to 80% want to stop). 9th August 2009 RAMPAL

6. There are 1.1 billion smokers Unless we take very action to change the trend: 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 (WHO) 9th August 2009 RAMPAL

7. 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%

8. Four Stages of the Tobacco Epidemic: Mortality Is Increasing in Many Countries 1 % female deaths 0 Sub-Saharan Africa 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 China Japan Southeast Asia Latin America North Africa Eastern Europe Southern Europe Western Europe, UK USA Canada Australia 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.

9. Developing Countries 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

10. 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

11. 9th August 2009 RAMPAL

12. 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

13. Fig 13:“Youth should be inculcated in a “ Calture without Tobacco”- Chairman ASH IQSW 2000 9th August 2009 RAMPAL

14. 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

15. Cigarettes remain the only legal product that kills half of its regular users when consumed as intended by the manufacturer. However, for all tobacco products, including cigarettes, information on tobacco ingredients and toxin deliveries remains inadequate. This gap needs to be filled with appropriate country-level regulation and further research. ( The World Health Organization ) 9th August 2009 RAMPAL

16. World No Tobacco Day Geneva, 30 May 2006 "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”. 9th August 2009 RAMPAL

17. DEADLY IN ANY DISGUISE 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. 9th August 2009 RAMPAL

18. WORLD HEALTH DAY 2007 “ 100% smoke-free environments as the only effective way to protect people everywhere from exposure to second-hand tobacco smoke”. 9th August 2009 RAMPAL

19. "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

20. Exposure to second-hand smoke occurs anywhere smoking is permitted: homes, workplaces and other public places. WHO estimates that around 700 million children, or almost half of the world's children, breathe air polluted by tobacco smoke, particularly at home. 9th August 2009 RAMPAL

21. ECONOMIC LOSS 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

22. RM 4.5 billion per year (US$1.3 BILLION/PER YEAR) 1 st JUNE 2007 9th August 2009 RAMPAL

23. 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

24. What’s in a Cigarette? Tobacco smoke:  4000 chemicals,  250 toxic or carcinogenic 1 Nicotine is addictive, but not carcinogenic 3 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

25. Chemicals 9th August 2009 RAMPAL

26. SMOKING ----> DISEASE ----> PREMATURE DEATHS FIRES CAUSED BY SMOKING MATERIALS SMOKING --------> DRUG ADDICTION ----> AIDS 9th August 2009 RAMPAL

27. 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

28. Mechanisms of Action: How Smoking Causes Disease Lung cancer Direct respiratory cell exposure to potent mutagens and carcinogens in tobacco smoke Ischemic heart disease Toxic products in the bloodstream create a pro-atherogenic environment 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.

29. 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

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31. There are more than 25 tobacco related diseases known today including : Cancer : Cancer of Lip, Oral Cavity and Pharynx, Oesophagus , Pancreas, Larynx, Lungs,trachea and bronchus Urinary Bladder , Kidney and other urinary organs (WHO 1999 . World No Tobacco Day- Health Consequence of tobacco use). 9th August 2009 RAMPAL

32. Merokok menyebabakan 90% daripada kematian akibat kanser paru-paru, 9th August 2009 RAMPAL

33. Tobacco is harmful to health it contain thousand s of chemical compound many are not only irritants and toxins but they are carcinogens 9th August 2009 RAMPAL

34. Common cancer among Tobacco chewing are -Oral cavity carcinoma -Oral Sub mucous fibrosis 9th August 2009 RAMPAL

35. INTRODUCTION Gamma-Glutamyl Transpeptidase (GGT) is a memberane bound enzyme present in many tissues and body fluids and it is one of the high diagnostic value in the internal Medicine Salivary GGT were studied in normal and cancer patients 9th August 2009 RAMPAL

36. Carcinoma of buccal mucosa Carcinoma of Maxilla 9th August 2009 RAMPAL

37. RESPIRATORY DISEASES TUBERCULOSIS PNEUMONIA AND INFLUENZA BRONCHITIS AND EMPHYSEMA ASTHMA CHRONIC AIRWAY OBSTRUCTION 9th August 2009 RAMPAL

38. CARDIOVASCULAR DISEASES HYPERTENSION ISCHAEMIC HEART DISEASE PULMONARY HEART DISEASE CERBROVASCULAR DISEASE ATHEROSCLEROSIS OTHER ARTERIAL DISEASES 9th August 2009 RAMPAL

39. Cardiovascular diseases are now responsible for 30% of all deaths worldwide. Smoking is a well-established risk factor for cardiovascular disease. 9th August 2009 RAMPAL

40. 38 YEARS SMOKER WHO DIED DUE TO WITH CEREBRAL STROKE 9th August 2009 RAMPAL

41. PAEDIATRIC DISEASES LOW BIRTH WEIGHT RESPIRATORY DISTRESS SYNDROME SUDDEN INFANT DEATH SYNDROME 9th August 2009 RAMPAL

42. Smoking During Pregnancy Harms Infants Exposure during pregnancy associated with 1–3 Increased risk of miscarriage, stillbirth, sudden infant death syndrome (SIDS); eg Low-birth weight 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

43. 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

44. IMPACT OF SMOKING ON MALE SEXUAL HEALTH Smoking increases the risk of erectile dysfunction by around 50 % for men in their 30s and 40s In MALAYSIA - How many ??? 9th August 2009 RAMPAL

45. 9th August 2009 RAMPAL

46. What Does Secondhand Smoke Do? Estimated lung cancer risk increased by 20%–30% 1 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

47. PREVALEVE OF SMOKING IN MALAYSIA 9th August 2009 RAMPAL

48. 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%

49. 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)

50. 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%

51. 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%

52. 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%

53. 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

54. Factors Influencing Tobacco Use 9th August 2009 RAMPAL

55. 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

56. Tobacco industry marketing, including product design, advertising, and promotional activities, is a factor influencing susceptibility to and initiation of smoking 7 . Billion are being spent (?wasted). 9th August 2009 RAMPAL

57. TOBACCO INDUSTRY TARGETTED YOUNG PEOPLE ( DYER C. BMJ 1998;316:1923 RJ Reynolds Marketing Plan -1975 “ The fragile , developing self image of the young persons needs all of the support and enhancement it can get….. This self image enhancement effect has traditionally been a strong promotional theme for cigarette brands and should continue to be emphasised”. Claude Teague, assistant chief, R&D ,Reynolds 1973 9th August 2009 RAMPAL

58. TOBACCO INDUSTRY – ADVERTISMENT?? 9th August 2009 RAMPAL

59. ON THE SIDE OF A SHOP TOBACCO INDUSTRY – ADVERTISMENT?? 9th August 2009 RAMPAL

60. RESTAURANT TOBACCO INDUSTRY – ADVERTISMENT?? 9th August 2009 RAMPAL

61. TOBACCO INDUSTRY – ADVERTISMENT?? 9th August 2009 RAMPAL

62. 2. NICOTINE ADDICTION 9th August 2009 RAMPAL

63. 9th August 2009 RAMPAL

64. Section 2: Tobacco Dependence Mechanisms Nicotine’s actions in the central nervous system Neurobiologic and physiologic effects of tobacco dependence Tobacco dependence and environmental reinforcement Symptoms of withdrawal

65. Mechanism of Action of Nicotine in the Central Nervous System Nicotine binds preferentially to nicotinic acetylcholinergic (nACh) receptors in the central nervous system; the primary is the  4  2 nicotinic receptor in the Ventral Tegmental Area (VTA) After nicotine binds to the  4  2 nicotinic receptor in the VTA, it results in a release of dopamine in the Nucleus Accumbens (nAcc) which is believed to be linked to reward  4  2  2  2  4  4  2 Nicotinic Receptor

66. Nicotine Stimulates Dopamine Release 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

67. 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.

68. The Cycle of Nicotine Addiction Nicotine binding causes an increase in release of Dopamine 1,2 Dopamine gives feelings of pleasure and calmness 1 The Dopamine decrease between cigarettes leads to withdrawal symptoms of irritability and stress 1 The smoker craves Nicotine to release more Dopamine to restore pleasure and calmness 1 Competitive binding of Nicotine to nicotinic acetylcholinergic receptors causes prolonged activation, desensitization, and upregulation 2 As Nicotine levels decrease, receptors revert to an open state causing hyperexcitability leading to cravings 1,2 1. Jarvis MJ. BMJ. 2004; 328:277-279. 2. Picciotto MR, et al. Nicotine and Tob Res . 1999: Suppl 2:S121-S125. Dopamine Nicotine

69. Tobacco Industry “ It has been suggested that 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

70. SMOKING IN UTERO INCREASES RISK OF LATER ADDICTION ARNOLD MANN NIDA, 2004: 19 (4) 9th August 2009 RAMPAL

71. 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

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74. REAL PRICE OF TOBACCO TO CONSUMER – PRICE WAR 9th August 2009 RAMPAL

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78. 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

79. PEERS SMOKING 9th August 2009 RAMPAL

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81. PARENTAL SMOKING 9th August 2009 RAMPAL

82. 9th August 2009 RAMPAL Risk factors Crude Odds Ratio P value Adjusted Odds Ratio P value Highest education achieved University/ College Secondary Primary No formal Education 1.00 1.61 (1.40, 1.86) 1.41 (1.2, 1.65) 0.98 (0.81, 1.19) <0.001 <0.001 0.846 1.00 2.22 (1.87, 2.64) 2.68 (2.18, 3.30) 6.61 (4.91, 8.89) <0.001 <0.001 <0.001 Friends who smoke No Yes 1.00 17.95 (15.25, 21.13) <0.001 1.00 4.9 (4.03, 5.96) <0.001 Family who smoke No Yes 1.00 1.58 (1.44, 1.74) <0.0001 1.00 2.20 (1.97, 4.47) <0.001 Self Esteem High Moderate Low 1.00 0.97 (0.88, 1.07) 1.29 (1.16, 1.45) 0.565 <0.001 1.00 0.92 (0.81, 1.04) 1.31 (1.13, 1.51) 0.185 <0.001

83. HOUSEHOLD AND WORKPLACE 9th August 2009 RAMPAL

84. GREED AND CORRUPTION 9th August 2009 RAMPAL

85. A letter from James F. Ripslinger to Sylvester Stallone dated June 14 1983 Mr Sylvester Stallone received $500,00.00 from B&W Tobacco Corp. for B & W appearances and usage in his 5 films Rhinestone Cowboy/ Godfather III /Rocky IV Rambo / 50/50 ASH(http://www.ash.org.uk) 9th August 2009 RAMPAL

86. It is sad that very few is calling for its BAN 9th August 2009 RAMPAL

87. Quitting at Any Age May Increase Life Expectancy 1. Doll R, et al. BMJ . 2004;328:1519–1527. Quitting sooner appears most beneficial Survival At Each Age Point (%) 40 35-44 Stopped Age Results From a Study of Male Physician Smokers in the United Kingdom Nonsmokers Cigarette Smokers Age (Years)

88. Risk of Cardiovascular Disease (CVD) Reduced By Quitting Smoking Quitting associated with 36% reduction in odds of all-cause mortality among patients with coronary heart disease (CHD) 1 Decreases in CVD events in cardiac patients, even in those who recently quit 2 *Defined as self-reported smokers who were cotinine negative. 1. Critchley JA, Capewell S. JAMA . 2003;290:86-97. 2. Twardella D et al. Eur Heart J . 2004;25:2101–2108. 0.71 0.64 0.44 1.00 0.00 0.20 0.40 0.60 0.80 1.00 1.20 Currently Smokes Recently Quit* Formerly Smoked Never Smoked Odds Ratio

89. COMBATTING THE PROBLEM 9th August 2009 RAMPAL

90. 1. CORE DEMAND REDUCTION 2. CORE SUPPLY REDUCTION 9th August 2009 RAMPAL

91. NGOs Role in tobacco control efforts should be focused on several fronts: Preventing people from taking up tobacco consumption; Promoting cessation Protecting non-smokers from the exposure to tobacco smoke Regulating tobacco products 9th August 2009 RAMPAL

92. WHO classifies interventions into two major groups, those aimed at reducing the demand for tobacco: Price and tax measures Protection from exposure to second-hand tobacco smoke Regulation and disclosure of the contents of tobacco products Packaging and labeling Education, communication, training and public awareness-raising Comprehensive bans and restriction on tobacco advertising, promotion and sponsorship Tobacco-dependence cessation measures; 9th August 2009 RAMPAL

93. and those aimed at reducing the supply of tobacco: Control of Smuggling has proven to be the key supply side measure 9th August 2009 RAMPAL

94. ROLE OF NGOs IN TOBACCO CONTROL 1. ADVOCATIVE 2. COMMUNITY LEADERSHIP 3. EDUCATIONAL 4. CATALYST 5. TRAINING AND CAPACITY BUILDING 6. RESEARCH 7. COMPLEMENTARY ROLE 9th August 2009 RAMPAL

95. MALAYSIAN EXPERIENCE 1982 to 2003 2004 to 2009 9th August 2009 RAMPAL

96. The major events organized by Action on Smoking and Health Committee (ASH), MMA in Tobacco Control Activities 1982-2004 with the co-operation of large number of organization 9th August 2009 RAMPAL

97. 1983 National workshop on smoking control 1984 Superman Campaign against smoking target at school children. About 7000 students directly participated in the campaign. All students who participated received a superman poster, sticker, comic and a certificate. 1985 National seminar on Smoking Control. 1986 NATIONAL NO SMOKING DAY (5 Nov.1986) 1987 NATIONAL NO SMOKING WEEK 1988 NATIONAL NO SMOKING WEEK 1989 NATIONAL NO SMOKING WEEK 1990 NATIONAL NO SMOKING WEEK 1991 NATIONAL NO SMOKING WEEK 1992 NATIONAL NO SMOKING WEEK 1993 NATIONAL NO SMOKING WEEK 1998 INTERNATIONAL QUIT AND WIN (NO SMOKING MONTH) 2000 INTERNATIONAL QUIT AND WIN (NO SMOKING MONTH) 2002 INTERNATIONAL QUIT AND WIN (NO SMOKING MONTH) These workshop, seminar and campaign served to create awareness, bring about change in government policy on tobacco control and highlight many different aspects of smoking control issues 2004 and 2006 INTERNATIONAL QUIT AND WIN (NO SMOKING MONT H) 9th August 2009 RAMPAL

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100. PARTICPATION FROM : MEDICAL ORGANISATIONS GOVERNMENT DEPARTMENTS HOSPITALS ACADEMIC / PROFESSIONAL INSTITUTIONS BANKS PRIVATE COMPANIES HOTELS 9th August 2009 RAMPAL

101. MMA SUBMITS MEMORENDAM TO GOVERNMENT TO BAN SMOKING IN PUBLIC PLACES 9th August 2009 RAMPAL

102. IMPACT: CABINET RULING BANS SMOKING IN GOVERNMENT MEETINGS AND PLACES 9th August 2009 RAMPAL

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105. LEAD ROLE :CATALYST ASH,MMA ORGANISES WORKSHOP ON SMOKING OR HEALTH 1983 9th August 2009 RAMPAL

106. SLIDE SHOWING WORKSHOP AND EXHIBITION “ON SMOKING OR HEALTH 9.10.1983 Dr RAMPAL 9th August 2009 RAMPAL

107. NATIONAL NO SMOKING DAY 6 TH NOV 1986 ORGANISED BY ASH, MMA WITH COLLABORATION WITH MOH AND OTHER NGO’S 9th August 2009 RAMPAL

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115. ROLE: EDUCATIONAL ASH, MMA HIGHLIGHTS HAZARDS OF PASSIVE SMOKING 9th August 2009 RAMPAL

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118. ROLE : EDUCATIONAL ASH, MMA HIGHLIGHTS ROLE OF HEALTH PROFESSIONALS IN TOBACCO CONTROL 9th August 2009 RAMPAL

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120. WORLD NO TOBACCO DAY 1993 9th August 2009 RAMPAL

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123. ROLE :ADVOCATIVE ASH MMA WRITES TO MALAYSIAN AIRLINES TO BAN SMOKING ON LOCAL FLIGHTS 9th August 2009 RAMPAL

124. Impact Of Health Promotion And Advocacy 1982 Ban on cigarette advertisement on television and radio. No smoking is permitted in any government meetings. 1983-2002 Increase in excise duties and taxes on tobacco. 1989Total ban on smoking during South East Asian Games, held in KL. 1990 Ban on smoking in prisons. 1991 Ban on smoking in all institutions and facilities. Ban on smoking in all cinemas in all local authorities in Malaysia The Ministry of Health declared all its hospitals and Health centres as smoke free. The D. General of Prisons has declared all prisons as smoke free. 1992 Many private sector offices, factories have declared their areas as No Smoking Zones 9th August 2009 RAMPAL

125. Impact Of Health Promotion And Advocacy 1998 : International Quit Smoking and Win competition and National Art competition &quot;Growing up without Tobacco&quot; 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

126. ASH, MMA SUBMITS MEMORENDAM TO GOVERNMENT TO BAN SMOKING IN PUBLIC PLACES 9th August 2009 RAMPAL

127. IMPACT BAN ON SMOKING ON MALAYSIAN AIRLINES 9th August 2009 RAMPAL

128. IMPACT BAN ON SMOKING ON MALAYSIAN AIRLINES BAN ON SMOKING IN PUBLIC TRANSPORT BAN ON SMOKING IN PUBLIC 9th August 2009 RAMPAL

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132. ROLES: LEAD AND CATALYST 9th August 2009 RAMPAL

133. INTERNATIONAL QUIT SMOKING AND WIN CAMPAIGN – MALAYSIA 1998, 2000, 2002 , 2004 9th August 2009 RAMPAL

134. Rules and Regulations 1. Open to the general public aged 18 and above 2. Open to smokers who have smoked for a minimum of 1 year prior to 1 st May . 3. Closing date for applications: 30 th April Entry form could be obtained from all Ministry of Health Government Hospitals, Health Centres, Malaysian Medical Association Secretariat, National Cancer Council and Malaysian Heart Foundation 9th August 2009 RAMPAL

135. Forms appearing in the Nation Newspaper and photocopied forms were be accepted. Participants were randomly selected using table of random numbers. Interviews and Urine test were carried out for those short listed 8. Judges decision was Final 9th August 2009 RAMPAL

136. NATIONAL LEVEL 1 st . Prize : RM 3,000 2 nd Prize : RM 2,000 3rd Prize :RM 1,000 30 Consolation prizes: Air Ticket/ Hotel stays/ Hampers etc INTERNATIONAL LEVEL The first Prize winner at the National level will have a chance to win US10,000.00 at the International Level PRIZES 9th August 2009 RAMPAL

137. PANEL OF JUDGES Assoc Prof Dr Lekhraj 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

138. 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

139. Assisted by: Major TV Stations Radio Major Newspapers –English, Malay Chinese and Tamil language dailies 9th August 2009 RAMPAL

140. The IQSW application forms were published in the English, Malay, Chinese and Tamil Language Newspapers which had Nation-wide circulation. 9th August 2009 RAMPAL

141. IQSW 1998 POSTER 9th August 2009 RAMPAL

142. 1998 ACTIVITIES i) International Quit Smoking and Win Competition (Talks, Exhibitions, TV and Press Interviews) ii) National Art competition with the theme &quot;Growing up without Tobacco&quot; More than 2000 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. 9th August 2009 RAMPAL

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144. Fig 10: International Quit Smoking And Win Campaign 1998-Malaysia 9th August 2009 RAMPAL

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146. 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

147. ROLE : ADVOCATIVE ASH,MMA WRITES TO MINISTRY OF HEALTH TO HAVE WARNING MESSAGES ON CIG. PACKETS 9th August 2009 RAMPAL

148. 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

149. Fig 14: President Malaysian Medical Association and Chairman ASH Slam Tobacco Firms Over Warning Labels 9th August 2009 RAMPAL

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151. DR RAMPAL 9th August 2009 RAMPAL

152. Launched by Deputy Minister of Health, Malaysia 9th August 2009 RAMPAL

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155. ROLE :ADVOCATIVE ASH MMA WRITES TO THE GOVERNMENT TO INCREASE TAX ON TOBACCO AND HAVE A SPECIAL FUND FOR TOBACCO CONTROL ACTIVITIES 9th August 2009 RAMPAL

156. Message form Prof Dr Lekhraj Rampal Chairman, ASH, MMA on World No Tobacco Day 31 st May 2007 Major TV stations and Newspapers and again on 2 July 2007 TV 2 TOBACCO PRICE WAR - Decline in tobacco price going in Malaysia ???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

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169. WE CAN QUIT SMOKING Fig 11: Bank Staff Quit As A Group During IQSW 1998 9th August 2009 RAMPAL

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173. DEPUTY MINISTER OF HEALTH QUITS SMOKING 9th August 2009 RAMPAL

174. Fig. 5: Launching of the No Smoking Week 1987 . Deputy Minister of Health. Kicks The Habit Himself (30 Years As a Smoker) 9th August 2009 RAMPAL

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176. GETTING THE HEALTH PROFESSIONALS IN THE ARMED FORCES INVOLVED 9th August 2009 RAMPAL

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179. 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 . 9th August 2009 RAMPAL

180. NGOs Roles include: Role Model: In your society and your communities you are expected to act on the basis of this knowledge. In your society and your communities your are expected to be role models for the rest of the population. 9th August 2009 RAMPAL

181. As Scientist 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. 9th August 2009 RAMPAL

182. As a Leader Many of you have leadership positions at different levels and several considerable public trust. As professionals who belong to professional organizations YOU can also influence your organization to become involved in tobacco control policy-making, and to place tobacco in the organization’s agenda. 9th August 2009 RAMPAL

183. Opinion-builder Your role to build opinion in support of tobacco control has great potential but has been neglected by most NGOs to date. 9th August 2009 RAMPAL

184. Alliance-builder You can be form alliances as individuals, between societies and organizations . 9th August 2009 RAMPAL

185. Watch out for tobacco industry activities NGOs have a duty to denounce tobacco industry strategies aimed at hindering local, national or international tobacco control efforts. In addition, health professionals need to take a stand against the pervasive and negative influence of tobacco industry money in many aspects of our society. 9th August 2009 RAMPAL

186. BARRIERS TO NGOs INVOLVEMENT IN TOBACCO CONTROL Lack of knowledge and skills about tobacco and tobacco control: Lack of organizational leadership 3. Continued tobacco consumption among NGOs Members 9th August 2009 RAMPAL

187. ROLE:TRAINING HEALTH PROFESSIONALS IN SMOKING CESSATION TECHNIQUES 9th August 2009 RAMPAL

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191. PARTICIPATION IN LOCAL AND INTERNATIONAL CONFERENCES AND FORUMS 9th August 2009 RAMPAL

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193. DR PETO AT WORLD CONFERENCE IN FINLAND 9th August 2009 RAMPAL

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195. Dr Judith Mackay at APACT Conference in Taiwan 9th August 2009 RAMPAL

196. MALAYSIAN HEALTH PROMOTION BOARD 9th August 2009 RAMPAL

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198. YOUTH INVOLVEMENT 9th August 2009 RAMPAL

199. DEPUTY MINISTER OF YOUTH AND SPORTS LAUCHES TOBACCO CONTROL ACTIVITIES AMONGST THE YOUTH USING INTERACT AND ROTERACT CLUBS 9th August 2009 RAMPAL

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201. TOBACCO FREE SPORTS NATIONAL ART POSTER & SLOGAN COMPETITION INTERNATIONAL QUIT SMOKING AND WIN 2002 THEME: TOBACCO FREE SPORTS 9th August 2009 RAMPAL

202. Organized by MMA AND COMMONWEALTH MEDICAL ASSOCIATION 9th August 2009 RAMPAL

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205. IMPACT ON THE MEMORENDUM GIVEN BY ASH, MMA TO THE GOVERNMENT TO INCREASE TAXES AND USE THE MONEY FOR TOBACCO CONTROL ACTIVITIES- SIN TAX 9th August 2009 RAMPAL

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211. 2005 WORLD NO TOBACCO DAY Launched by MINISTER OF WILAYAH PERSEKTUAN 31.5.2005 AT UNIVRSITY MALAYA 9th August 2009 RAMPAL

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216. WINNERS OF COMPETITION BEING GIVEN PRIZES 9th August 2009 RAMPAL

217. USING ART AND CULTURE IN TOBACCO CONTROL 9th August 2009 RAMPAL

218. 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

219. NATIONAL ART POSTER COMPETITION - 2005 ORGANIZED BY ASH, MMA 1300 ENTRIES FROM ALL STATES IN MALAYSIA PARTICIPATED 9th August 2009 RAMPAL

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221. JUDGES SELECTING THE WINNERS MR VICTOR CHIN (PROFESSIONAL ARTIST ) 9th August 2009 RAMPAL

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223. PROF DR KRISHNA GOPAL TRUSTEE NATIONAL ART MUSEUM 9th August 2009 RAMPAL

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227. CHAIRMAN ASH,MMA DR RAMPAL WITH THE WINNERS 9th August 2009 RAMPAL

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230. PLEASE ADVOCATE TO EXTEND THE EXISTING BAN TO INCLUDE 9th August 2009 RAMPAL

231. CADANGAN PERLUASAN KAWASAN LARANGAN MEROKOK Komitmen Negara terhadap FCTC - Article 8, - “Protection from exposure to tobacco smoke” Melindungi orang awam dan warga kerja terutamanya kanak-kanak, remaja, wanita dan orang yang tidak merokok daripada bahaya asap rokok Kementerian Kesihatan Malaysia akan memperluaskan kawasan larangan merokok meliputi : Lobi Hotel Tempat Kerja Tertutup ( Enclosed Workplace ) Semua Tempat Makan (gerai, kedai, restoran dan pusat penjaja) 9th August 2009 RAMPAL

232. IN CONCLUSION: YOU AND YOUR NGOs CAN PLAY THE FOLLOWING ROLES IN TOBACCO CONTROL 1. ADVOCATIVE 2. COMMUNITY LEADERSHIP 3. EDUCATIONAL 4. CATALYST 5. TRAINING AND CAPACITY BUILDING 6. RESEARCH 7. COMPLEMENTARY ROLE 9th August 2009 RAMPAL

233. IN CONCLUSION: Malaysia has taken several steps forward in tobacco control. We need to work together locally and globally to achieve – “ A Tobacco Free World”. 9th August 2009 RAMPAL

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