Risk Factors for Smoking in the EMR Region Kawkab Shishani, BSN, PhD The Hashemite University Epidem

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Risk Factors for Smoking in the EMR Region
Kawkab Shishani, BSN, PhD The Hashemite
UniversityEpidemiology of Diabetes Other
Non-Communicable DiseasesAlexandria, Egypt
6-13th January 2009
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Petra Jordans Wonder of the World
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Objectives

• Describe the scope of the problem
• Examine smoking among selected populations
• Differentiate between forms of tobacco use
• Discuss why smoking is harmful
• Value WHO position on tobacco control
• Summarize how health care professionals can
  provide the leadership in tobacco control

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Question

• Why it is important to study smoking ?
• Smoking is the chief avoidable risk factor for
  NCDs
• Smoking Affects the progression of NCDs (gt
  complications)
• Unlike the other risk factors such as physical
  activity and nutrition that affects only those
  who do not comply to them, smoking affects smoker
  as well as those around

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Why Do Farmers Grow Tobacco?

• The wealth generated by leaf tobacco production
  helps to improve quality of life and attracts
  educational, health and social facilities in,
  otherwise, relatively impoverished, rural areas.
• International tobacco growers association
  http//www.tobaccoleaf.org/about_itga/index.asp?op
  1

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Scope of the Problem

• 1,3 billion smokers
• 80 in developing countries
• 20 in developed countries
• The number is expected to increase by 1.7 per
  cent annually
• By 2030, 80 of deaths due to tobacco will occur
  in developing countries

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Scope of the Problem

• Most cigarettes consumed worldwide are
  international brands
• As smoking rates in the US and Europe is
  declining, new markets are needed
• Globalization made it easy for companies to
  access new markets internationally (Asia, Africa,
  Middle East)

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Smoking Men and Women

• Global smoking (M 4gt F)
• ? in smoking rates in F gt M
• Ratio of smoking M F
• Developed countries 31
• Developing countries 71

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Smoking Men and Women

• EMR country profilehttp//www.emro.who.int/TFI/Cou
  ntryProfile

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Smoking Men and Women

• 50-66 of women use light
• Addiction in MgtF
• Biological responses to nicotine differ between
  M F
• Smoking in women is reinforced by less nicotine
  than in men (Perkins et al., 1991)

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Female Smoking Low Birth Weight

• www.globalheathfactt.org

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Smoking Youth

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

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Youth Smoking in EMR
EMR country profilehttp//www.emro.who.int/TFI/Cou
ntryProfile
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I can't stop smoking. I am addicted to cigarettes.
Smoking Youth

• Parent (father smokes)
• Access to cigarettes
• Peer pressure
• Experimentation
• Imitating adults

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Smoking Health Professionals
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GHPS Jordan
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GHPS Jordan
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Forms Of Tobacco Use

• Waterpipe
• Cigarettes
• Chewing

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Second Hand Smoking

• At home
• Smoking around children
• Children prepare waterpipe for parents
• Cultural issues
• Public places (hospitals, buses, taxis,..)

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Waterpipe The Emerging Epidemic

• Myths
• It is safe alternative for cigarettes (WHO study
  group , 2005)
• Chemicals filtered by the water (bubbling)
• Not addictive can quit anytime (Asfar et al.
  BMC Public Health 2005)
• Highest rates are in MENA (Shihadeh., 2004)
• Social practice (Café employees)
• Children smoke with their parents (Maziak et al.,
  2004)

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Waterpipe The Emerging Epidemic

• Nicotine in 1 head of unflavored tobacco 70
  regular cigarettes
• Flavored tobacco 20cigarettes
• A single smoking session 2.25 mg nicotine, high
  levels of arsenic, cobalt, chromium, and lead
  (Shihadeh, 2003)
• Cotinine levels are almost the same among
  waterpipe and cigarette smokers (Bacha, Salameh,
  Waked , 2007)

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Chemicals Produced From Smoking

• Nicotine
• Tar
• Carbon monoxide
• Benzopyrene
• Cyanide hydrogen

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How Does Nicotine Work?
From Benowitz N. Nicotine Addiction. Primary Care
1999 26(3)611-31
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Why Nicotine Matters

• Short term effect Long term effect

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Tobacco Dependence A Chronic Disease

• The long delay between the onset of smoking and
  associated morbidities
• 70 of the smokers want to quit Unsuccessful
• 44 tried to quit
• Only 7 succeed

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Tobacco Dependence A Chronic Disease

• A Chronic disease model
• Long term nature
• Minimum number achieve permanent abstinence
• Periods of relapse and remissions
• No ideal intervention
• Emphasis on education and counseling (same like
  in DM, HTN)
• (US Department of Health and Human Services,
  2008)

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WHO Efforts to Control Tobacco Use (FCTC)

• Price and tax measures
• Protection from exposure to tobacco smoke
• Educational and public awareness programmes
• Promoting the cessation of tobacco use
• Sales to and by minors
• Research, surveillance and exchange

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Where Do We Go From Here?

• Monitoring tobacco use to provide accurate
  tracking of epidemiological data about the extent
  of tobacco exposure (GTSS)
• Report morbidities associated with smoking
• Public Education (media, curricula)
• Health Insurance companies (reimburse tobacco
  dependence treatments)

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Why Do We Need A Plan in EMR

• Lack of human resources (experienced in tobacco
  control
• Lack of adequate studies on hazards of smoking
• Research encouragement (Funding)
• http//www.emro.who.int/tfi/CountryProfile-Part6.

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2008 Update
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5 As

• A1. AskSystematically identify all tobacco users
  at every visit
• A2. AdviseStrongly urge all tobacco users to
  quit
• A3. AssessDetermine willingness to make a quit
  attempt
• A4. AssistAid the patient in quitting (provide
  counseling and medication)
• A5. ArrangeEnsure follow-up contact
• Treating Tobacco Use and Dependence 2008
  Update Clinical Guideline

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Elements of Counseling

• Problem 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

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Format of Counseling

• Assessment
• Program clinician
• Program intensity
• Format
• Type of counseling
• Medication
• Population
• Treating Tobacco Use and Dependence 2008
  Update Clinical Guideline