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Role of DPHS in Tobacco endgame Malaysia

Dr Lydia Mason Dental Public Health Specialist

BDS ,MPH(OH)University Malaya

Dr L Mason 12 March 2017 1 8th MADPHS Conference 2017

Dr L Mason 12 March 2017 8th MADPHS Conference 2017 2

1. Advice from dentists and health provider can be effective in motivating patients to quit (Dolan,1997; Hastreiter,1994; Kreuter ,2000, Cohen,1989)

2. Patient expects and welcome such advice

(Solberg,2001) 3. Meta analysis on school based

interventions report various successes in prevention, increasing quit attempt, delaying onset, increasing cessation (Bancej,2007;Sussman,2006;Dobbins,2007)

Page 12 - © IPCRG 2007Page 12 - © IPCRG 2007Page 12 - © IPCRG 2007

A smoking aware practice

Adapted from Litt J, et al. Asia Pacific Fam Med. 2003; 2: 175-9

Increase in

quit rate

GP time

A ‘no-smoking practice’

Brief intervention

Moderate intervention

Intense

intervention

>5 mins

<1 mins

2-5 mins

2 fold

3 fold

4 fold

5-7 fold

Dentists are well placed for Tobacco control

Tobacco use : A public health problem

• Tobacco consumption continues to be the leading preventable cause of death in the world.

• As research and findings continue to show the negative effects of tobacco consumption on health and the number of affected people increases, the list of conditions caused by tobacco consumption has grown.


Dental Concern vs smoking Oral cancer :

6th commonest cancer

in Malaysia

Bad breath

Poor aesthetics

Gum problems

Tooth loss

Poor treatment

outcomes

Dry mouth

Increase RISKS

Johnson and Bain , 2000

Bergstrom J, 1983,1989, Gelskey SC, Young TK, Singer 1998

Early presentations


Magnitude of the problem

• Currently, there are an estimated 1.3 billion

smokers in the world. The death toll from tobacco consumption is now 4.9 million people a year;

• If present consumption patterns continue, the

number of deaths will increase to 10 million

by the year 2020, 70% of which will occur in

developing countries



MALAYSIA SCENARIO

• Smoking is the #1 cause of preventable death in Malaysia: – 11,000 deaths every year

• 20% of all deaths

• 90% of all preventable deaths

• Half of all smokers will die from their addiction, losing, on average, 15 years of their life and quality of Life

Harms the economy and sustainable development

Widen gap of poverty ( lower social economic grps most affected)

5 million smokers@ average 14 sticks/day is equivalent to

5 Million x rm17/pack = RM105 Million /day

Tobacco use = Regressive habits

Addictive and need to consume more to get similar effect as years go by


2015 Smoking Prevalence

NHMS 2015 Dr L Mason 12 March 2017 8 8th MADPHS Conference 2017

The sad thing is ….. those who consume tobacco are not the only ones exposed to its negative effects.


Passive smokers

• Millions of people, including one half of the

world’s children, are exposed to second-hand tobacco smoke, known also as passive smoking

• Passive smoking is a health problem that requires society’s active effort



Passive smoker– at home

• Approximately 30-40% of Malaysians are exposed to second hand smoke in their homes

• Children and women are most likely to be exposed

DPHS • DPHS have a prominent role to play in tobacco

control.

• They have the trust of the population, the media and opinion leaders, and their voices are heard across a vast range of social, economic and political arenas


Role

1. Protecting people from taking up tobacco consumption;

2. Promoting cessation

3. Protecting non-smokers from the exposure to tobacco smoke

4. Regulating tobacco products.


DPHS placements

• MOH-different level of care

• MOD

• MOHE

• Universities (Public and Private)

• Solo practices (DPHS in Private practice)

• Members of NGOs

• Alliance


As health professional

• DPHS can educate the population on the harms of tobacco use and exposure to second-hand smoke.

• Get involved actively in early prevention and

• Offer help to tobacco users to overcome their addiction and

• Provide quit advises


At Community level

• DPHS professionals can be initiators or supporters of some of the policy measures by engaging in efforts to promote smoke-free environment and extending the availability of tobacco cessation resources to their caption groups


At Societal level

• DPHS can add their voice and their weight to national and global tobacco control efforts like

tax increase campaigns and become involved at the national level in promoting the WHO Framework Convention on Tobacco Control (WHO FCTC )


Leadership

DPHS should become a role model for other professional organizations and society by embracing the tenants of the Health Professional Code of Practice on Tobacco Control.


Research for evidence

• No matter where DPHS are

• We need evidence for best practice


Advocacy for policy

• Watchdog

• Refer SEATCA

• Professional voice

• Build sound Public

Health Policy*


Opportunity for partnership and Alliance

In any setting

• Global

• Local

• Community

• Alliance with other Stake holders and NGOs


WHO FCTC


Price and tax measures to reduce the demand for tobacco,

and

Non-price measures to reduce the demand for tobacco,

namely:

Protection from exposure to tobacco smoke;

Regulation of the contents of tobacco products;

Regulation of tobacco product disclosures;

Packaging and labelling of tobacco products;

Education, communication, training and public awareness;

Tobacco advertising, promotion and sponsorship; and,

Demand reduction measures concerning tobacco

dependence and cessation

Illicit trade in tobacco products; Sales to

and by minors; and, Provision of support

for economically viable alternative activities

Member States that

have signed the

Convention indicate

that they will strive in

good faith to ratify,

accept, or approve it,

and show political

commitment not to

undermine the

objectives set out in it. We are signatories to FCTC and it is legal binding


A Global Thrust To Counter A Global Threat : FCTC + MPOWER + ENDGAME

FCTC (2003):Now 174 Countries Subscribe To The Treaty .Malaysia has signed and ratified.

SEATCA

South East Asia Tobacco Control Alliance

ASEAN Tobacco Control :TAPS WATCH


SEATCA is committed to work hand in hand with countries in ASEAN to promote health and save lives by

1. fast-tracking and effectively implementing the

evidence-based tobacco control measures contained in

the WHO FCTC.

promote increased participation and cooperation among

tobacco control advocates at the regional level,

organize regional forum for sharing lessons and best practices in advancing tobacco control policies,

act as a regional leader on issues that are priorities in all the countries in the region


DPHS in Universities • Capacity and capability building

• Curriculum/ teaching /building tobacco control skills

• Screening and intervention

• Cognitive behavioral therapy

• Balance decision guide

• Quit clinic with or without NRT

• Research community


DPHS in the Army

• ADS

• Clinical setting


DPHS in MOH

• Clinical setting

• School based approach

• Outreach programmes



School based tobacco use prevention interventions has been

shown be effective in smoking prevention, control and

cessation.

Sources:Dobbins,2007; Grimshaw and Stanton ,2006; Sussaman, 2006;

MMWR,1994;Bancej et al,2007;

The most promising one for MOH

The school based –dental approach

• Ambitious concept

• Achievable strategies



Very few people begin smoking as older adults

• The earlier they start smoking,

the more heavily smokers they are going to become and the less like they are going to stop (Nicotine addiction: chief mechanism to renew pool of smokers )

( US Surgeon’s Report,2000; MMWR,1998; Grimshaw and Stanton,2009 )

Thus preventing youth

from smoking is critical

to ending the epidemic

of tobacco use WHO ,2007

Source:McKinlay,1979

Upstream approach


Rationale why school service is targeted

1.Adolescents are difficult to enrolled in clinic based quit clinic services due to many barriers. (Disciplinary ,punitive, privacy , consent, time ,transport, money )and are helpless on their own.

2.School-based setting provide ease of enrollment , follow up, reduce barriers ,decrease attrition .Socially acceptable (do not discriminate smokers/non smokers) and F.O.C.

3. Use of SDS can optimize service and reduce costs

4. Adolescents = a caption group who can be used to promote health to their peers, families and communities


Rationale for using SDS

1. Potentially high number of adolescent smokers attending the SDS every year (From and annual pool of 7 million students )

2. Annual OH screening (From primary 1- Form 5): allow for long term follow up to follow through the stages of change in smoking behaviour

3. Detection of nicotine stain on teeth and smokers breath during oral examination provides an opportunity for teachable moments in TC as well as detection of smokers.


TOBACCO USE, ADOLESCENTS 13 – 15 YRS (GYTS MALAYSIA 2003 & 2009)

Prevalence 2003 2009

Overall Boys Girls Overall Boys Girls

Ever smoked cigarette 33.1 % 54.6 % 11.5 % 30 % 46.7 % 12.4 %

Ever smokers, 1st

smoke cig < 10 yrs

old

16.4 % 14.1 % 28.8 % 22.8 % 19.3 % 35.9 %

Currently smoking

cigarette

20.2 % 36.3 % 4.2 % 18.2 % 30.9 % 5.3%

Currently using other

tobacco products

8.1 % 8.8 % 7.5 % 9.5 % 13.0 % 5.7 %

Never smokers likely

to initiate smoking in

the next year

15.5 % 21.4 % 12.4 % 10.7 % 15.7 % 7.7 %

YEAR 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Mil

lio

n

* TOTAL POPULATION (Age ≥ 15)

20.8 21.6 22.0 22.4 22.8 23.2 23.5 23.9 24.3 24.7 25.0 25.3 25.7 26.0 26.3

NO. OF SMOKERS 4.70 4.86 4.83 4.78 4.74 4.69 4.61 4.55 4.49 4.42 4.33 4.23 4.15 4.05 3.94

NO. OF QUITTERS

0.13 0.13 0.13 0.13 0.13 0.14 0.14 0.14 0.14 0.15 0.15 0.15 0.15 0.15

PREVALENCE (%) 23.1 22.5 21.9 21.4 20.8 20.2 19.6 19.0 18.5 17.9 17.3 16.7 16.1 15.6 15.0

MALAYSIA’S TOBACCO CONTROL ROAD MAP FOR 2014 – 2025 Target : To reduce smoking prevalence to 15% by 2025

23.1 22.52 21.94 21.36 20.78 20.2 19.62 19.04 18.46 17.88 17.3 16.72 16.14 15.56 14.98

0

5

10

15

20

25

0.00

1.00

2.00

3.00

4.00

5.00

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Population (Million)

NO. OF SMOKERS (Million) NO. OF QUITTERS…

Prevalence



Endgame Concepts On The Table

‘Endgame’ is a strategic plan to reduce prevalence within a set period (E.g. To < 5% globally by the year 2045)

• De-normalizing tobacco use

• Tobacco-free Generation Malaysia (No sale to those born after the year 2009) (S’pore , Thailand : those born from 2000)

• Focusing on supply-side measures; nicotine regulation

taxation and price controls

• Addressing tobacco as a systemic issue

• Removing profitability from the business of tobacco

• Making the tobacco industry liable

Our Biggest hope=endgame reforms

• Tobacco free generation

• Those born from 2009 onwards

• As of 2016 –we have data serveillance

• We will follow through cohorts

• We will produce serveillance data for the country

• Work with PAKEJ IMFREE ( HED,MySIHAT,MOE)


Endgame reforms

• Children born from 2009 onwards –don’t smoke/use tobacco

• Decline in onset /initiation

• Decline in prevalence

• Increase in quit

• Smoking gets to a tipping point where it becomes easier to regulate OR even ban


Endgame reforms

• High public understanding of the tobacco burden

• Rapid reduction in tobacco use prevalence

• Support from all stake holders and civil societies movement

• Strong leadership

• Strong Political Will ***


WHA78

END GAME OF TOBACCO

15% <5%

2025 2045


Can DPHS help fast track ???

Development of personal skills in Tobacco intervention



FIORE’S MODEL: 5A’s and 5R’s

Cigarette pattern • Cigarette record (time, situation, urge, mood)

No Time Activity Urge

Mood

1 Strong , Moderate Light

Sad Angry Relax

2

3

4

5

6

7

8

10


Tests for level of addiction

The Fagerstrom Nicotine Dependence Questionnaire

AND OR validation with Smokerlyzer


The Fagerstrom Nicotine Dependence Questionnaire

1. How soon after you wake up do you smoke your first cigarette? (circle appropriate number)

a. Within 5 minutes …………………………………………………………………….. 3 b. 6-30 minutes …………………………………………………………………………… 2 c. 31-60 minutes ………………………………………………………………………….. 1 d. After 60 minutes …………………………………………………………………….. 0

2. Do you find it difficult to refrain from smoking in places where it is forbidden (such as schools, theaters, libraries, etc.)?

a. Yes …………………………………………………………………………..………… 1 b. No ……………………………………………………………………………………… 0

3. Which of all cigarettes you smoke in a day is the most satisfying?

a. The first one in the morning ……………………………………………………………. 1 b. Any other ……………………………………………………………………………..... 0

4. How many cigarettes do you smoke a day?

a. 10 or less ……………………………………………………………………………….. 0 b. 11-20 …………………………………………………………………………………… 1 c. 21-30 …………………………………………………………………………………… 2 d. 31 or more ……………………………………………………………………………… 3

5. Do you smoke more in the morning than during the rest of the day?

a. Yes ……………………………………………………………………………………… 1 b. No ………………………………………………………………………………………. 0

6. Do you smoke if you are so ill that you are in bed most of the day?

a. Yes ………………………………………………………………………………………1 b. No ……………………………………………………………………………………….0

Your Score __________ Score 0-5 = low to moderate nicotine dependence 6-10 = high nicotine dependence


The Hooked on Nicotine Checklist

1. Have you ever tried to quit but couldn't?

2. Do you smoke now because it is really hard to quit?

3. Have you ever felt like you were addicted to tobacco?

4. Do you ever have strong cravings to smoke?

5. Have you ever felt like you really needed a cigarette?

6. Is it hard to keep from smoking in places where you are

not supposed to, like school?

In answering the last four questions, when you tried to stop

smoking, or when you have not used tobacco for a while ...

7. Did you find it hard to concentrate?

8. Did you feel more irritable?

9. Did you feel a strong need or urge to smoke?

10. Did you feel nervous, restless or anxious because you

couldn't smoke?


The Horn’s test

1.Find out why they smoke

2. List the reasons in order of priority

3. Discuss strategies to deal with the problems


Why do you smoke? • Here is a list of things people say about why they smoke. Next to each one write the number that applies to you:

5 = Always 4= Frequently 3= Occasionally 2= Seldom 1= Never A. I smoke in order to keep from slowing down………………………………………………………….._____ B. Handling a cigarette is a part of the enjoyment of smoking it………………………………………_____ C. Smoking cigarettes is pleasant and relaxing………………………………………………………….._____ D. I light up when I feel angry about something…………………………………………………………._____ E. If I run out of cigarettes I find it almost unbearable…………………………………………………._____ F. I smoke automatically, without even being aware of it………………………………………………_____ G. I smoke to stimulate me, to perk myself up……………………………………………………………._____ H. Part of the enjoyment of smoking comes from the steps I take to light up…………………………_____ I. I find cigarettes pleasurable…………………………………………………………………………….._____ J. When I feel uncomfortable or upset, I light up a cigarette………………………………………….._____ K. I am very much aware when I am not smoking……………………………………………………….._____ L. I light up a cigarette without realizing I still have one burning in the ashtray…………………..._____ M. I smoke to give myself a “lift”………………………………………………………………………….._____ N. I like watching the smoke when I exhale it……………………………………………………………._____ O. I want a cigarette most when I feel relaxed……………………………………………………………_____ P. When I feel “blue” or want to take my mind off my cares, I smoke a cigarette………………….._____ Q. I get a real gnawing hunger for a cigarette when I haven’t smoked for a while…………………._____ R. I’ve found a cigarette in my mouth and didn’t remember putting it there…………………………_____


How to score

• Enter the number you have placed for each question in the space below. Place the number for question A over line A, for question B over line B, etc. Add across the three scores on each line to get your totals. ___ ____ ____ ________________________ A + G + M = Stimulation ____ ____ ____ ________________________ B + H + N = Handling ____ ____ ____ ________________________ C + I + O = Pleasurable Relaxation ____ ____ ____ ________________________ D + J + P = Tension Reduction ____ ____ ____ ________________________ E + K + Q = Craving ____ ____ ____ _________________________ F + L + R = Habit

• Scores can vary from 3 to 15. Any score 11 or above is high; any score 7 or below is low


Stages of change

Are you ready to quit?

Stages of change? 1.Precontemplation

2.Contemplation

3.Action

4.Maintainance

5.Relapse

Assess willingness to quit?


Dealing with ambivalence


Decision-Making Worksheet The pros and cons of quitting

Pros

1.Good things about smoking

2.Good things about quitting

3.Reasons for making a change

Cons

1.Not so good things about smoking

2.Not so good thing about quitting

3.Reason for staying the same


Reasons for wanting to quit What are some reasons for you to quit using

tobacco? ___ Health ___ Family health ___ Cost ___ It’s a bad habit ___ Good role model ___ Social pressure ___ I don’t like being addicted ___ My family wants me to quit ___ Doctor’s advice ___ I have no reason to quit ___ Other ___________________________________________


Barriers and roadblocks

What do you think are your barriers to quitting tobacco use right now? ___ I don’t believe I can do it. ___ I enjoy tobacco use too much. ___ I have too many friends/ family who use tobacco. ___ I don’t believe using tobacco will hurt me. ___ I have too much stress in my life to quit now and I won’t be able to deal with it without using tobacco. ___ If I quit I will gain weight. ___ Using tobacco is the least of my problems right now. ___ Quitting might hurt my recovery from alcohol or other drugs. ___ I will miss or crave tobacco too much. ___ I will become too nervous or anxious or tense when I quit. ___ Other ______________________________________________


Motivation and efficacy

Use the scale below to answer the following 4 questions. ______________________________________ 0 1 2 3 4 5 6 7 8 9 10 Not at all Extremely

a. How motivated are you to become tobacco-free at this time? ___ ___

b. How confident are you in your ability to become tobacco-free at this time? ___ ___

c. How effective do you believe your skills are for becoming tobacco-free? ___ ___

d. How much effort are you willing to put into becoming tobacco-free at this time? ___ ___


Preparing them to quit

• Anticipate challenges

– Ask about cues to use tobacco

• Practice problem-solving

– enlisting help from friends or parents, quitting with a friend, getting parents to quit

• Prescribe or provide information about pharmacotherapy

– Pharmacotherapy can be used, but has not been shown effective with teens (Mixed results…)

• Help the teen set a quit date

• Document your advice

• PLAN pathway to quit


Anticipate Tobacco Withdrawal

• Cigarette craving

• Anxiety

• Irritability

• Headache

• Insomnia

• Drowsiness

• Constipation

• Increased appetite

• Poor attention

• Impaired cognitive performance

• Decreased heart rate

Symptoms occur within hours of stopping smoking, and may persist for weeks


Quit method 1. Self quit -Cold Turkey

2. Cutting down and quit

3. Quit with Medication

58 8th MADPHS Conference 2017 Dr L Mason 12 March 2017

Cravings

1. For many smokers‚ the craving for

a cigarette lasts longer than the other symptoms of withdrawal.

2. This is because cravings can be set off by reminders of smoking.

3. These reminders are sometimes called triggers. There are many people, places, and things that trigger a craving.

• This means it's important to have a plan for how you'll handle a craving when it hits.


http://smokefree.gov/cravings



Withdrawal

1. Although withdrawal can be uncomfortable and some people may feel high levels of symptoms‚ there is no health danger from nicotine withdrawal.

2. In fact‚ quitting smoking is the best thing you can do for your health.

3. Even extreme withdrawal symptoms will fade in a week or so.

If you feel very sad and depressed …See a doctor


How long do they lasts?

1. For most people, the worst of the symptoms only last a few days to a couple weeks

2. Many people just can't handle it

3. They start smoking again to feel better.

4. Most people slip up in the first week after quitting. This is when feelings of withdrawal are strongest.

• It helps to be prepared and know what to expect so you can stay smokefree.


Who should consider medication?

1. Those who have tried several times without success

2. Smokes one pack per day or more

3. Bothered by cravings and withdrawals for nicotine


Learning from failures 1. Most people who have quit smoking

were unsuccessful at least once in the past.

2. Try not to view past attempts to quit as failures.

3. See them as learning experiences. Expect relapses when you try to quit. On the average one need to undergo 6-7 cycles before final success.

“Quit smoking for a healthier you. Every

cigarette you don’t smoke is doing you good.”


Motivational Interviewing

• motivation to change by exploring and resolving ambivalence

Prof Wee will elaborate tomorrow


Cognitive behavioural therapy (CBT)

• is a talking therapy that can help you manage your problems by changing the way you think and behave


Motivation and benefit



Audit /Monitoring

Output /process indicators:

1. % asked

2. % smokers advised

3. % referred to quit services

4. Client’s satisfaction and feedback

Outcome Indicators

1.Reduction in overall

prevalence

2.Percentage remained

non smokers

3.Rate of Quit attempt

4.Rate of Cessation

Impact indicators

Decrease in uptake

Increase in quit attempt

Decrease in relapse

Improvement in

Oral Health: less

with nicotine

stains, bad breath,

gum problems etc

School based Achievements PPIM Selangor 2010-2015

Students given brief intervention Smokers detected


12491

0

15763

0

17808

0

19512

15405

21502

16059

23076

15723

0

5000

10000

15000

20000

25000

sm interven sr interven

2010

2011

2012

2013

2014

2015

0

50

100

150

200

250

300

350

400

450

500

smokers

259

367

466

398

470

430

2010

2011

2012

2013

2014

2015

Between 250 -500 pts can be Detected for smoking each year Prevalence : 2 - 5.2%


Passive smokers Secondary school Passive Smokers Primary School


0

1000

2000

3000

4000

5000

6000

passive smokers

3521

3832

4804 4973

5374

5203

2010

2011

2012

2013

2014

2015

More than 25% of students are expose to passive smoking

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

passivesmokers

enrolment

5154

15405

4826

16059

4510

15723

2013

2014

2015

About 25% primary students subjected to passive smoking


Smokers Quit


0

50

100

150

200

250

formersmokers

158 171

201 221 229

2101

2011

2012

2013

2014

2015

0

100

200

300

400

500

smokers

259

367

466

398

470 430

2010

2011

2012

2013

2014

2015


Between 150-230

Quit each year

Prevalence : about 30 %


YEAR 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Mil

lio

n

* TOTAL POPULATION (Age ≥ 15)

20.8 21.6 22.0 22.4 22.8 23.2 23.5 23.9 24.3 24.7 25.0 25.3 25.7 26.0 26.3

NO. OF SMOKERS 4.70 4.86 4.83 4.78 4.74 4.69 4.61 4.55 4.49 4.42 4.33 4.23 4.15 4.05 3.94

NO. OF QUITTERS

0.13 0.13 0.13 0.13 0.13 0.14 0.14 0.14 0.14 0.15 0.15 0.15 0.15 0.15

PREVALENCE (%) 23.1 22.5 21.9 21.4 20.8 20.2 19.6 19.0 18.5 17.9 17.3 16.7 16.1 15.6 15.0

MALAYSIA’S TOBACCO CONTROL ROAD MAP FOR 2014 – 2025 Target : To reduce smoking prevalence to 15% by 2025

23.1 22.52 21.94 21.36 20.78 20.2 19.62 19.04 18.46 17.88 17.3 16.72 16.14 15.56 14.98

0

5

10

15

20

25

0.00

1.00

2.00

3.00

4.00

5.00

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Population (Million)

NO. OF SMOKERS (Million) NO. OF QUITTERS…

Prevalence


The next steps : The extended intervention

8th MADPHS Conference 2017 72

1.If project approved : Collaborate with R&D communities to undertake research (NARCC,CERIA,NIH) to evaluate project .

2.If project feasible : Advocacy for policy .

Expansion of

Smoking

prevention

Programmes

nationwide

Scope under

Dental Public Health

specialty

Consider:

Incentives

Improve Career pathway

Funding Dr L Mason 12 March 2017

Future Direction

• Can we propose M’sian school base Tobacco endgame to FCTC ?

• 176 WHO member country can benefit from this

• Imply room for global expansion

• We could be consultant for APW Tobacco Endgame for WHO if this happens

(APW =acceptance performance for work)


DPHS Role and Contributions ??



DPHS contributions in Tobacco control 1.To the MOH organization

Establishment of health surveillance systems ( Routine cohort data) Improve utilization of quit clinic

Consolidations of health services vs smoking 2.To the country

Improve health of population , QoL Reduce costs treating smoking related disease 3.To the school children and adolescents

Improve access to care and prevention 4.To the Dental Services Added value to SDS and dental professionals

5. To the world if globally implemented*


Issues and Challenges

1. Lack of confidence

2. Time constraints

3. Patient resistant

4. Confidentiality

5. Supportive environment

6. Leaderships**, organizations

7. Limitations :Validation of self –report

8. Budget for sustainability

Urine cotinine

Serum cotinine

Salivary cotinine

Breath analyzer

Dip stick

Another individual

Nothing that cannot be resolved ***

Conclusion

• Governments and legislators have a role to play for smoke free Malaysia, but they are not the only ones.

• Society at large needs to be involved in the struggle against tobacco.


FOR SURE …..

Within society, one group of professionals has

a special role to play because they practice their

profession in a particular sector –

The Dental Public Health Specialist



Thank you

You and I , Together we can make a difference

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