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

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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
Characteristic Women (n) Men (n) Total (n)
Once started clinical work smoking Decreased Stayed the same Increased Do you want to quit smoking Yes No Have 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)
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GHPS Jordan
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
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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