How to Fight the Tobacco Epidemic

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How to Fight the Tobacco Epidemic

• Presentation to Portfolio Committee on the
  Tobacco Products Control Amendment Bill, 23
  January 2007
• C T Bolliger

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History of Tobacco

• A.D. 600 Maya stone carvings
• 1492 Columbus tobacco to Europe
• 16th cty Sultan Constantinople smokers to be
  quartered, or at least beheaded
• 1604 James I A Counterblaste to Tobacco AND
  big revenue by tax !!!
• 1798 Benjamin Rush, colonial physician
  condemns tobacco
• 19th cty moderate consumption - pipe, cigars,
  chew, sniffing
• 1881 cigarette-rolling machine - safety matches

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History of Tobacco

• 1906 The Dukes investing up to 80 of profit
  into advertising
• 20th cty smoking epidemic
• 1945 cigarette dominant
• 1964 Luther Terry, First Surgeon Generals
  report
• 1998 EC advertising ban voted
• 2003 FCTC (signed by gt 100 countries by June
  2004, !!! ? ratified)

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Prevalence
Sources WHO, National Centre for Health
Statistics, Japan Tobacco Inc., Comité Français
dÉducation pour la Santé, Serbian Ministry of
Health, The World Bank, SADHS,
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Advertising banned in SA since 2001

• Switzerland (15-74yrs) 33
• latest (2002) 30.5
• 15-24 yo. 37.4
• South Africa (gt18yrs, SADHS 98) 24
• latest (2004) 22

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Cigarette prices and consumption (S.A.) C van
Waalbeek
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Composition of the retail price of cigarettes
(S.A.) C van Walbeek
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S.A.governments achievements

• Advertising ban
• Price increase
• Restaurants

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Projected annual tobacco-related deaths

• Year Total 1.World 3.World
• 1950 300.000 300.000 -
• 1965 1.000.000 900.000 100.000
• 1975 1.500.000 1.300.000 200.000
• 1995 3.000.000 2.000.000 1.000.000
• 2000 3.500.000 2.400.000 1.100.000
• 2025 10.000.000 3.000.000 7.000.000
• Mackay JL. Tuber Lung Dis 1994758-24

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Perceived risks of CAD and Cancer in Smokers

• MI Cancer
• Current smokers 29 40
• ? 40 cig/day 39 49

Ayanian JZ. JAMA 19992811019-21
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Never smokedregularly
100 80 60 40 20 0
Current ciga-rette smokers
80
59
7.5 years
Alive
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40 55 70 85 100 Age
(Doll R., BMJ 1994 309901-11. 35 539 doctors x
40 years)
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Never smoked regularly Former smokers Continuing
cigarette smokers
100 80 60 40 20 0
Alive
Former smokers stopped 35 - 44
Former smokers stopped 45 - 54
100 80 60 40 20 0
Alive
Former smokers stoped 55 - 64
Former smokers stopped gt 65
40 55 70 85 100 40 55 70 85 100
Age Age
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50 of long-term smokers die from their habit
Doll R. BMJ 1994
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Risk factors for MI
Yusuf S, Lancet 2004364937-52
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Smoking is the most important preventable cause
of disease
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Law MR. BMB 19965222
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Effect of number of cigarettes smoked at home
Risk factor
1 1 - 10 11 - 20 gt 20
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Milk CausesCancer !
Milk CausesCancer !
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Desired nicotine actions

• Arousal
• Relaxation (in stress)
• Improved mood
• Increased concentration
• Increased vigilance
• Shorter reaction time
• Weight control
• Regular bowel movements

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Effects of Nicotine on the BrainImproves mood
and influences Memory
Frontal brain steers behaviour, remembers after
years that nicotine triggers feeling of
well-beingt.
Nucleus Accumbens responsible for feeling of
well-being. Nerve cells secret mainly dopamine
Hippocampus stores memories in cooperation with
frontal brain.
Amygdala Emotions are processed.
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Nicotine withdrawal symptoms (DSM-III)

• Craving for tobacco
• Irritability
• Anxiety
• Difficulty concentrating
• Restlessness
• Headaches
• Drowsiness
• GI tract disturbances

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How to quit? Most smokers need professional help

• National Quitline 011 720 3145
• GP
• Smoking cessation specialist
• Smoking cessation Clinic
• Faculty of Health Sciences,U.S. 021 938 9423

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The 5 As

• Ask Smoker?
• Advise Quit!
• Assess Willing?
• Assist Aid!
• Arrange Follow-up!

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Practical smoking cessation

• Screening visit phone, computer? (motivation?!)
• Initial interview GP/ nurse (day 0 40 - 1 h)
• Info about withdrawal symptoms
• Coping strategies
• Change of life style
• Pharmaceutical Aids? ( 3/12)
• Nonsmoker at once
• Intensive follow-up (p.e. weeks 1, 2, 4, 8, 12,
  16, 20, 26, 52)
• Occasionally intensive group therapy

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Nicotine replacement therapy

• Patch (15 - 25 mg 16h or 24 h)
• Chewing gum (2 or 4 mg)
• Mouth spray (1mg/actuation)
• Nasal spray (0.5 mg / puff)
• Inhaler (13 mg / puffs 80 puffs 1 mg 1
  Cig.)
• Lozenges (1mg)
• Sublingual tablets (2 mg)

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TØnnesen NEJM 1991, 325311
100 80 60 40 20 0
Active Placebo
Abstainers ()
N 145 n 144
0 1 3 6 12 26 52
30 20 10
Patch size cm2
Weeks
40
Continuous Abstinence during Follow-Up
?


? plt0.001, OR 2.24, 95 CI 1.45, 3.56
Plt0.001 OR 2.34 95 Cl 1.43, 3.98

P0.002 OR 2.19 95 Cl 1.29, 3.86

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Take home message

• For the doctor
• Smoking is highly addictive (Nicotine)
• Smokers underestimate health risk 50 will be
  killed long-term
• Smokers need professional help to quit
• Pharmaceutical aids double success rate
• For the politician
• S.A. so far very good job with legislation
• Tabacco companies not to be underestimated
• Tobacco Products Control Amendment Bill needs
  endorsement to achieve further reduction in
  tobacco consumption