Risk Factors for Smoking in the Risk Factors for Smoking in the EMR Region EMR Region

Kawkab Shishani, BSN, PhD Kawkab Shishani, BSN, PhD The Hashemite UniversityThe Hashemite University

Epidemiology of Diabetes & Other Non-Communicable Diseases

Alexandria, Egypt 6-13th January 2009

Petra: Jordan’s Wonder of the WorldPetra: Jordan’s Wonder of the World

ObjectivesObjectives

1.1. Describe the scope of the problemDescribe the scope of the problem

2.2. Examine smoking among selected populationsExamine smoking among selected populations

3.3. Differentiate between forms of tobacco useDifferentiate between forms of tobacco use

4.4. Discuss why smoking is harmfulDiscuss why smoking is harmful

5.5. Value WHO position on tobacco controlValue WHO position on tobacco control

6.6. Summarize how health care professionals can provide Summarize how health care professionals can provide

the leadership in tobacco controlthe leadership in tobacco control

Question Question

Why it is important to study smoking ?Why it is important to study smoking ?

1.1. Smoking is the chief avoidable risk factor for NCDsSmoking is the chief avoidable risk factor for NCDs

2.2. Smoking Affects the progression of NCDs (> complications)Smoking Affects the progression of NCDs (> complications)

3.3. Unlike the other risk factors such as physical activity and Unlike the other risk factors such as physical activity and

nutrition that affects only those who do not comply to them, nutrition that affects only those who do not comply to them,

smoking affects smoker as well as those around smoking affects smoker as well as those around

Why Do Farmers Grow TobaccoWhy Do Farmers Grow Tobacco??

The wealth generated by leaf tobacco production helps The wealth generated by leaf tobacco production helps to improve quality of life to improve quality of life and attracts educational, and attracts educational, health and social facilities in, otherwise, relatively health and social facilities in, otherwise, relatively impoverished, rural areas. impoverished, rural areas.

International tobacco growers association International tobacco growers association http://www.tobaccoleaf.org/about_itga/index.asp?op=1http://www.tobaccoleaf.org/about_itga/index.asp?op=1

Scope of the ProblemScope of the Problem

1,3 billion smokers:1,3 billion smokers: 80% in developing countries80% in developing countries 20% in developed countries20% in developed countries

The number is expected to increase by 1.7 per cent The number is expected to increase by 1.7 per cent annuallyannually

By 2030, 80% of deaths due to tobacco will occur in By 2030, 80% of deaths due to tobacco will occur in developing countriesdeveloping countries

Scope of the ProblemScope of the Problem Most cigarettes consumed worldwide are Most cigarettes consumed worldwide are

international brandsinternational brands

As smoking rates in the US and Europe is As smoking rates in the US and Europe is declining, new markets are neededdeclining, new markets are needed

Globalization made it easy for companies to Globalization made it easy for companies to access new markets internationally (Asia, Africa, access new markets internationally (Asia, Africa, Middle East)Middle East)

Smoking: Men and WomenSmoking: Men and Women

Global smoking (M: 4> F)Global smoking (M: 4> F)

↑↑ in smoking rates in F > M in smoking rates in F > M

Ratio of smoking M: FRatio of smoking M: F

Developed countries 3:1Developed countries 3:1

Developing countries 7:1Developing countries 7:1

Smoking: Men and WomenSmoking: Men and Women

EMR country profilehttp://www.emro.who.int/TFI/CountryProfileEMR country profilehttp://www.emro.who.int/TFI/CountryProfile

Smoking: Men and WomenSmoking: Men and Women

50%-66% of women use 50%-66% of women use “light”“light”

Addiction in M>FAddiction in M>F

Biological responses to nicotine Biological responses to nicotine

differ between M & Fdiffer between M & F

Smoking in women is reinforced by Smoking in women is reinforced by

less nicotine than in men less nicotine than in men (Perkins et al., 1991)(Perkins et al., 1991)

Female Smoking & Low Birth Weight Female Smoking & Low Birth Weight

www.globalheathfactt.orgwww.globalheathfactt.org

Smoking: YouthSmoking: Youth

WHO (2007). Sifting the evidence: Gender and tobacco control WHO (2007). Sifting the evidence: Gender and tobacco control

Youth Smoking in EMRYouth Smoking in EMR

EMR country profilehttp://www.emro.who.int/TFI/CountryProfile

I can't stop smoking. I am addicted to cigarettesI can't stop smoking. I am addicted to cigarettes..

Smoking: YouthSmoking: Youth

Parent (father smokes)Parent (father smokes)

Access to cigarettes Access to cigarettes

Peer pressure Peer pressure

ExperimentationExperimentation

Imitating adultsImitating adults

Smoking: Health ProfessionalsSmoking: Health Professionals

0

10

20

30

40

50

60

70

80

EMR Egypt Jordan Saudia

Smoker

Former

Non-smoker

GHPS: JordanGHPS: JordanCharacteristic Women

% (n)Men

% (n)Total

% (n)Once started clinical work smoking Decreased Stayed the same IncreasedDo you want to quit smoking

Yes NoHave you ever tried to quit Yes No How many times you tried to quit 1-3 times

34.4 (32)35.5 (33)30.1 (93)

62.0 (54)37.9 (33)

54.9 (50) 45.1 (41)

77.8 (28)

24.2 (104)34.7 (149)41.0 (176)

52.0 (216)48.0 (199)

61.9 (255)38.1 (157)

37.9 (161)

26.1(136)34.9 (182)39.1 (204)

53.8 (270) 46.2(232)

60.6(305)39.4 (198)

74.4 (189)

Learning Need Assessment Nurses%

Physicians%

Total %

Cigarettes and argileh are both addicting

Taught in classes about dangers of smoking

Discuss in any of your classes why people smoke

Ever received any formal training in smoking cessation

Provide materials to support smoking cessation to patients

(Shishani, Nawafleh, & Sivarajan Froelicher, 2008)

37.2

65.7

53.1

35.9

54.2

52.2

72.5

60.6

26.6

63.6

41.9

67.6

55.1

32.3

56.9

GHPS: JordanGHPS: Jordan

Forms Of Tobacco UseForms Of Tobacco Use

WaterpipeWaterpipe

CigarettesCigarettes

Chewing Chewing

Second Hand SmokingSecond Hand Smoking

At home: At home:

Smoking around childrenSmoking around children

Children prepare waterpipe for parents Children prepare waterpipe for parents

Cultural issuesCultural issues

Public places (hospitals, buses, taxis,..)Public places (hospitals, buses, taxis,..)

Waterpipe: The Emerging EpidemicWaterpipe: The Emerging Epidemic Myths:Myths:

It is safe alternative for cigarettesIt is safe alternative for cigarettes (WHO study group , 2005) (WHO study group , 2005)

Chemicals filtered by the water (bubbling)Chemicals filtered by the water (bubbling) Not addictive; can quit anytime Not addictive; can quit anytime (Asfar et al. BMC Public Health 2005)(Asfar et al. BMC Public Health 2005)

Highest rates are in MENA Highest rates are in MENA (Shihadeh., 2004)(Shihadeh., 2004)

Social practice (Café employees)Social practice (Café employees)Children smoke with their parents Children smoke with their parents (Maziak et al., 2004)(Maziak et al., 2004)

Waterpipe: The Emerging EpidemicWaterpipe: The Emerging Epidemic Nicotine in 1 head of unflavored tobacco = 70 Nicotine in 1 head of unflavored tobacco = 70

regular cigarettes;regular cigarettes; Flavored tobacco = 20cigarettesFlavored tobacco = 20cigarettes A single smoking session: 2.25 mg nicotine, high A single smoking session: 2.25 mg nicotine, high

levels of arsenic, cobalt, chromium, and lead levels of arsenic, cobalt, chromium, and lead ((Shihadeh, 2003) Shihadeh, 2003)

Cotinine levels are almost the same among Cotinine levels are almost the same among waterpipe and cigarette smokers waterpipe and cigarette smokers ((Bacha, Salameh, Waked , 2007)Bacha, Salameh, Waked , 2007)

Chemicals Produced From Smoking Chemicals Produced From Smoking

Nicotine Nicotine

TarTar

Carbon monoxideCarbon monoxide

BenzopyreneBenzopyrene

Cyanide hydrogenCyanide hydrogen

How Does Nicotine Work?How Does Nicotine Work?

From Benowitz N. Nicotine Addiction. Primary Care 1999; 26(3):611-31

Why Nicotine MattersWhy Nicotine Matters

Short term effectShort term effect Long term effectLong term effect

Tobacco Dependence: A Chronic DiseaseTobacco Dependence: A Chronic Disease

The long delay between the onset of smoking The long delay between the onset of smoking

and associated morbiditiesand associated morbidities

70% of the smokers want to quit 70% of the smokers want to quit UnsuccessfulUnsuccessful

44% tried to quit44% tried to quit

Only 7% succeed Only 7% succeed

Tobacco Dependence: A Chronic DiseaseTobacco Dependence: A Chronic Disease

A Chronic disease model: A Chronic disease model: Long term natureLong term nature Minimum number achieve permanent Minimum number achieve permanent

abstinenceabstinence Periods of Periods of relapserelapse and remissions and remissions No ideal interventionNo ideal intervention Emphasis on education and counseling (same Emphasis on education and counseling (same

like in DM, HTN) like in DM, HTN) (US Department of Health and Human Services, 2008)(US Department of Health and Human Services, 2008)

WHO Efforts to Control Tobacco Use WHO Efforts to Control Tobacco Use (FCTC)(FCTC)

Price and tax measuresPrice and tax measures

Protection from exposure to tobacco smokeProtection from exposure to tobacco smoke

Educational and public awareness programmesEducational and public awareness programmes

Promoting the cessation of tobacco usePromoting the cessation of tobacco use

Sales to and by minorsSales to and by minors

Research, surveillance and exchangeResearch, surveillance and exchange

Where Do We Go From Here?Where Do We Go From Here?

Monitoring tobacco use to provide accurate tracking Monitoring tobacco use to provide accurate tracking

of epidemiological data about the extent of tobacco of epidemiological data about the extent of tobacco

exposure (GTSS)exposure (GTSS)

Report morbidities associated with smokingReport morbidities associated with smoking

Public Education (media, curricula)Public Education (media, curricula)

Health Insurance companies (reimburse tobacco Health Insurance companies (reimburse tobacco

dependence treatments)dependence treatments)

Why Do We Need A Plan in EMRWhy Do We Need A Plan in EMR

Lack of human resources (experienced in tobacco Lack of human resources (experienced in tobacco

controlcontrol

Lack of adequate studies on hazards of smoking Lack of adequate studies on hazards of smoking

Research encouragement (Funding) Research encouragement (Funding)

http://www.emro.who.int/tfi/CountryProfile-Part6.http://www.emro.who.int/tfi/CountryProfile-Part6.

2008 Update2008 Update

55 AsAs

A1. Ask—Systematically identify all tobacco users at every visit

A2. Advise—Strongly urge all tobacco users to quit

A3. Assess—Determine willingness to make a quit attempt

A4. Assist—Aid the patient in quitting (provide counseling and medication)

A5. Arrange—Ensure follow-up contact

Treating Tobacco Use and Dependence: 2008 Update” Clinical Guideline

Elements of CounselingElements of CounselingProblem solving/ skills training

Recognize danger situations –Develop coping skills- Identify and practice coping

Provide basic information

Supportive treatment

Encourage the patient in the quit Attempt

Communicate caring and concern.Encourage the patient to talk about the quitting process.

Treating Tobacco Use and Dependence: 2008 Update” Clinical Guideline

Format of CounselingFormat of Counseling

Assessment Program clinician Program intensity Format Type of counseling Medication Population

Treating Tobacco Use and Dependence: 2008 Update” Clinical Guideline