role of ng os in tobacco control

THE ROLE OF NGOsIN TOBACCO CONTROL

Prof. Dr Lekhraj Rampal

MBBS, MPH, DRPH, FRSH, FAMM

Deputy Chairman Malaysian Health Promotian Board

Chairman, Action on Smoking and Health Committee, MMA 1993, 1996 -2009

Chairman, International Quit smoking and Win – MALAYSIA 1998, 2000, 2002, 2004,2006

Chairman, National Organizing Committee- World No Tobacco Day – Malaysia1993, 2002, 2004,2006

9th August 2009 1RAMPAL

CONTENTS

• GLOBAL IMPACT OF TOBACCO USE ON HEALTH

• FACTOR INFLUENCING (ASSOCIATED WITH)TOBACCO USE

• ROLE OF NGOs IN TOBACCO CONTROL


• UNDERSTANDING AND COMBATING THE PROBLEM


THE GLOBAL IMPACT OF SMOKING ON HEALTH

• Smoking is the major preventable cause of disease in the world.

• Tobacco kills

• It causes more than four million (4,000,000) deaths per year

(WHO )


The 5 million deaths per year from tobacco smoking are not the result of liberty and free choice by adult and responsible consumers (60 to 80% want to stop).


There are 1.1 billion smokers

Unless we take very action to change the trend:

• Two Hundred and Fifty Million ( 250,000,000) children alive today eventually will die from smoking

- ABOUT HALF A BILLION ( 500,000,000) PEOPLE ALIVE TODAY WILL DIE FROM SMOKING

(WHO)


Gender-Specific Smoking Prevalence Across the World

1. Mackay J, et al. The Tobacco Atlas. Second Ed. American Cancer Society Myriad Editions Limited, Atlanta, Georgia, 2006. Also available online at: http://www.myriadeditions.com/statmap/.

US24%19%

MenWomen Australia

19%16%

Belarus53%7%

Brazil22%14%

Canada22%17%

Chile48%37%

China67%2%Egypt

45%12%

France30%21%

Iceland25%20%

Mexico13%5%

Iran22% 2%Kenya

21%1%

Sweden17%18%

Philippines41%8%

Portugal33%10%

South Africa23%8%

India47%17%

Russian Fed60%16%

Italy33%17%

Spain39%25%

Germany37%28%

% female deaths

0

• Sub-Saharan Africa

Four Stages of the Tobacco Epidemic: Mortality Is Increasing in Many Countries1

If current smoking patterns continue, deaths from smoking in Asia—home to a third of the world’s population—are expected to increase by 2020 to 4.9 million annually.2

Percentage of smokers among adults

Percentage of deaths caused by smoking

• China• Japan• Southeast Asia• Latin America• North Africa

• Eastern Europe• Southern Europe

• Western Europe, UK

• USA• Canada• Australia

STAGE 1

STAGE 2

STAGE 3

STAGE 4

70

60

50

40

30

20

10

0

706050403020100 80 90 100

40

30

20

10% male deaths

% male smokers%

female smokers

Years

1. Lopez AD, et al. Tobacco Control. 1994;3:242-247. 2. Shafey O, et al (eds). Tobacco Control Country Profiles 2003, American Cancer Society; 2003; Atlanta, Georgia. Available at: http://www.who.int/tobacco/global_data/country_profiles/en/. Accessed June 2006.

Developing Countries

• As smoking rate decline in the wealthy nations, the tobacco pandemic has moved to the developing countries

• 80 % of them live in low and middle income countries


Every day , THOUSANDS of young people around the world are trying their first cigarette and 80,000 – 100,000 are becoming regular smokers often precipitating a lifetime of addiction and untimely death.


Annual Deaths Attributable to Tobacco: Worldwide Estimates

Canada>25%

Australia20%-24%

UK>25%

Germany >25%

China & Taiwan

10%-14%

Brazil 15%-19%

% of Total Deaths Attributable to Tobacco*

*Regional estimates in 2000 in men aged >35 years.1. Mackay J, Eriksen M. The Tobacco Atlas. Second Ed. World Health Organization; 2006.

US >25%

Mexico 15%-19%

Argentina 15%-19%

Spain>25%

Russian Federation>25%

Sweden >25%

Turkey>25%


Fig 13:“Youth should be inculcated in a “Calture without Tobacco”- Chairman ASHIQSW 2000


Tobacco must be seen as a drug, not as a more agricultural product.

Tobacco is a dangerous product and hazardous to health and it is lethal.


• Cigarettes remain the only legal product that kills half of its regular users when consumed as intended by the manufacturer.

• However, for all tobacco products, including cigarettes, information on tobacco ingredients and toxin deliveries remains inadequate.

• This gap needs to be filled with appropriate country-level regulation and further research.

(The World Health Organization )


World No Tobacco Day Geneva, 30 May 2006

"Tobacco: deadly in any form or disguise," focusing on the fact that all tobacco products are addictive, harmful and can cause death, regardless of the form, packaging, or name under which they are presented to the public”.


DEADLY IN ANY DISGUISE

• There is a need for strict regulation and encourage its implementation.

• Smokeless tobacco products, such as snus and snuff are being marketed heavily to specific target groups:

women (in cultures where it is not socially acceptable for them to smoke); young people (presented with flavoured and milder-tasting "starter" products); or to smokers (as an alternative in smoke-free environments).

• At the same time, forms of non-cigarette smoking, such as waterpipes, also known as "shishas", "narghiles" or "hubble-bubbles", are gaining wider acceptance around the world, especially among young people in cafés and on college campuses.


WORLD HEALTH DAY 2007

“100% smoke-free environments as the only effective way to protect people everywhere from exposure to second-hand tobacco smoke”.


• "The evidence is clear, there is no safe level of exposure to second-hand tobacco smoke,"

• I urge all countries that have not yet done so to take this immediate and important step to protect the health of all by passing laws requiring all indoor workplaces and public places to be 100% smoke-free."

WHO Director-General Dr Margaret Chan.


• Exposure to second-hand smoke occurs anywhere smoking is permitted: homes, workplaces and other public places.

• WHO estimates that around 700 million children, or almost half of the world's children, breathe air polluted by tobacco smoke, particularly at home.


ECONOMIC LOSS

• The costs of second-hand smoke are not limited to the burden of disease.

• Exposure also imposes economic costs on individuals, businesses and society as a whole.

• These include primarily direct and indirect medical costs, but also productivity losses.

• In addition, workplaces where smoking is permitted incur higher renovation and cleaning costs, and increased risk of fire, and may experience higher insurance premiums.


RM 4.5 billion per year (US$1.3 BILLION/PER YEAR)

1st JUNE 2007


Estimated Annual Costs Attributable to Tobacco

Canada$12.9

Australia$14.2

France$16.4

Germany$24.4

China$4.3US

$184.5

Estimated Costs to the Economy Attributable to Tobacco (US $ Billions)

UK$2.3

Norway$1.62

1. Mackay J, et al. The Tobacco Atlas. Second Ed. American Cancer Society Myriad Editions Limited. Atlanta, Georgia, 2006. Also available online at: http://www.myriadeditions.com/statmap/.

Venezuela $.284Total Costs

Direct Healthcare Costs


What’s in a Cigarette?• Tobacco smoke: 4000 chemicals, 250 toxic

or carcinogenic1

• Nicotine is addictive, but not carcinogenic3

• Smoking cigarettes with lower tar and nicotine provides no health benefit4

Chemical in Tobacco Smoke2 Also Found In…

Acetone Paint stripper

Butane Lighter fluid

Arsenic Ant poison

Cadmium Car batteries

Carbon monoxide Car exhaust fumes

Toluene Industrial solvent

1. National Toxicology Program. 11th Report on Carcinogens; 2005. Available at: http://ntp-server.niehs.nih.gov. 2. Mackay J, Eriksen M. The Tobacco Atlas. World Health Organization; 2006. 3. Harvard Health Letter. May 2005. 4. Surgeon General’s Report. The Health Consequences of Smoking; 2004.

Chemicals9th August 2009 25RAMPAL

• SMOKING ----> DISEASE ----> PREMATURE DEATHS

• FIRES CAUSED BY SMOKING MATERIALS

• SMOKING --------> DRUG ADDICTION ----> AIDS


Tobacco is the only freely available product which, when used as intended by the manufacturer, kills half of its dedicated users.


Mechanisms of Action: How Smoking Causes Disease

• Lung cancer– Direct respiratory cell exposure to potent mutagens and

carcinogens in tobacco smoke

• Ischemic heart disease– Toxic products in the bloodstream create a

pro-atherogenic environment – Leads to endothelial injury and dysfunction, thrombosis,

inflammation, and adverse lipid profiles

• Chronic Obstructive Pulmonary Disease (COPD)– Accelerated decline in respiratory function

1. Surgeon General’s Report. The Health Consequences of Smoking; 2004.

Smoking: Leading Preventable Cause of Disease and Death1

Top 3 Smoking-Attributable Causes of Death in US#1 Lung cancer

#2 Ischemic heart disease#3 COPD

CancerLung (#1)* Leukemia

(AML, ALL, CLL)2-4

Oral cavity/pharynx LaryngealEsophageal StomachPancreatic KidneyBladder Cervical

CardiovascularIschemic heart disease (#2)*Stroke – Vascular dementia5 Peripheral vascular disease6

Abdominal aortic aneurysm

RespiratoryCOPD (#3)*PneumoniaPoor asthma control

ReproductiveLow-birth weightPregnancy complicationsReduced fertilitySudden Infant Death Syndrome

OtherAdverse surgical outcomes/wound healingHip fracturesLow-bone densityCataractPeptic ulcer disease†

*Top 3 smoking-attributable causes of death. †In patients who are Helicobacter pylori positive.AML = Acute myeloid leukemia; ALL = acute lymphocytic leukemia; CLL = chronic lymphocytic leukemia; COPD = chronic obstructive pulmonary disease; SIDS = sudden infant death syndrome.1. Surgeon General’s Report. The Health Consequences of Smoking; 2004. 2. Sandler DP, et al. J Natl Cancer Inst. 1993;85(24):1994-2003. 3. Crane MM, et al. Cancer Epidemiol Biomarkers Prev. 1996;5(8):639-644. 4. Miligi L, et al. Am J Ind Med. 1999;36(1):60-69. 5. Roman GC. Cerebrovasc Dis. 2005;20(Suppl 2):91-100. 6. Willigendael EM, et al. J Vasc Surg. 2004;40:1158-1165.


There are more than 25 tobacco related diseases known today including :

Cancer : • Cancer of Lip, Oral Cavity and Pharynx, • Oesophagus ,• Pancreas, • Larynx,• Lungs,trachea and bronchus• Urinary Bladder , • Kidney and other urinary organs

• (WHO 1999 . World No Tobacco Day- Health Consequence of tobacco use).


Merokok menyebabakan 90% daripada kematian akibat kanser paru-paru,


Tobacco is harmful to health it contain

thousand s of chemical compound many

are not only irritants and toxins but they are

carcinogens


Common cancer among Tobacco chewing Common cancer among Tobacco chewing areare -Oral cavity carcinoma -Oral cavity carcinoma

-Oral Sub mucous fibrosis -Oral Sub mucous fibrosis


INTRODUCTION

Gamma-Glutamyl Transpeptidase (GGT) is a

memberane bound enzyme present in many

tissues and body fluids and it is one of the high

diagnostic value in the internal Medicine

Salivary GGT were studied in normal and

cancer patients


Carcinoma of buccal mucosa Carcinoma of Maxilla 9th August 2009 36RAMPAL

RESPIRATORY DISEASES

• TUBERCULOSIS

• PNEUMONIA AND INFLUENZA

• BRONCHITIS AND EMPHYSEMA

• ASTHMA

• CHRONIC AIRWAY OBSTRUCTION


CARDIOVASCULAR DISEASES

• HYPERTENSION

• ISCHAEMIC HEART DISEASE

• PULMONARY HEART DISEASE

• CERBROVASCULAR DISEASE

• ATHEROSCLEROSIS

• OTHER ARTERIAL DISEASES


Cardiovascular diseases are now responsible for 30% of all deaths worldwide.

Smoking is a well-established risk factor for cardiovascular disease.


38 YEARS SMOKER WHO DIED DUE TO WITH CEREBRAL STROKE9th August 2009 40RAMPAL

PAEDIATRIC DISEASES

• LOW BIRTH WEIGHT

• RESPIRATORY DISTRESS SYNDROME

• SUDDEN INFANT DEATH SYNDROME


Smoking During Pregnancy Harms Infants

• Exposure during pregnancy associated with1–3 – Increased risk of miscarriage, stillbirth,

sudden infant death syndrome (SIDS); eg– Low-birth weight

• 4-fold risk1: eg, 9700–18,600 cases related to secondhand smoke annually in US*3

– Impaired infant lung function2

– Possible association with cognitive and developmental syndromes1,4

*1990s.1. Fagerström K. Drugs. 2002;62(Suppl 2):1–9. 2. Le Souef PN. Thorax. 2000;55:1063–1067. 3. Mackay J, et al. The Tobacco Atlas. World Health Organization; 2002. 4. Hellstrom-Lindahl E, et al. Respiration. 2002;69:289-293.


For every person who dies from tobacco use, another 20 suffer with at least one serious tobacco-related illness.

Half of all long-term smokers die prematurely from smoking-related causes.

Until recently this epidemic of chronic disease and premature deaths mainly affected the rich countries. It is now rapidly shifting to the developing world.


IMPACT OF SMOKING ON MALE SEXUAL HEALTH

• Smoking increases the risk of erectile dysfunction by around 50 % for men in their 30s and 40s

• In MALAYSIA - How many ???


What Does Secondhand Smoke Do?

• Estimated lung cancer risk increased by 20%–30%1

• Believed to cause and worsen diseases such as asthma, COPD, and emphysema2

• Increases risk for developing heart disease by 25%–30%1

• Increases risk of nonfatal acute myocardial infarction in a graded manner3

1. News release, June 27, 2006; US Department of Health & Human Services. Available at: http://www.hhs.gov/news/press/2006pres/20060627.html. 2. Mackay J, et al. The Tobacco Atlas. World Health Organization; 2002. 3. Teo KK, et al. Lancet. 2006;368:647-658.


PREVALEVE OF SMOKING IN MALAYSIA


1996 2004 2006

NHMS2 UPM NHMS3

(>18 yrs) (>18 yrs) (>18 yrs)

Overall 24.8% 23.2% 21.5%

Male 49.2% 47.2 46.4%

Female 3.5% 2.7% 1.6%

Malay 27.9% 28.9 % 24%

Chinese 19.2% 18.7% 16.2%

Indian 16.2% 16.8% 13.7%

Others 32.4% 22.5% 23.8%

Prevalence of Smoking among Malaysians

Estimated: ~ 3 million smokers in Malaysia (2006)9th August 2009 48RAMPAL

Table III: Prevalence of ever and current smokers by sex and ethnicity 2004

Ethnicity Sex Prevalence of Ever Smokers% (SE %)

Prevalence of Current Smokers% (SE %)

All Races MaleFemaleBoth

59.3 (0.7)4.8 (0.3)32.0 (0.5)

47.2 (0.7)2.7 (0.2)

24.9 (0.4)

Malay MaleFemaleBoth

69.8 (0.8)4.6 (0.3)

37.0 (0.6)

55.6 (0.9)2.6 (0.2)28.9 (0.6)

Chinese MaleFemaleBoth

45.2 (1.6)5.0 (0.6)

25.3 (1.0)

34.1 (1.5)3.0 (0.4)

18.7 (0.9)

Indian MaleFemaleBoth

41.1 (2.2)1.1 (0.3)21.1 (1.3)

33.4 (2.1)0.5 (0.2)

16.8 (1.2)

Others MaleFemaleBoth

55.4 (10.4)5.1 (2.0)27.5 (4.7)

46.1 (9.4)3.5 (1.6)

22.5 (4.4)

Bumiputra Sarawak

MaleFemaleBoth

61.2 (3.6)10.7 (1.9)35.8 (2.3)

50.9 (3.2)5.2 (1.4)

27.9 (2.0)

Bumiputra Sabah

MaleFemaleBoth

57.5 (2.4)5.5 (1.0)32.0 (1.6)

50.2 (2.2)2.6 (0.6)

26.8 (1.6)9th August 2009 49RAMPAL

NHMS3 - Adult Smoking Prevalence

Ever Smoker Current Smoker Ex-Smoker

Overall 27.0% 21.5%

(2.73M)

5.4%

Male 57.6% 46.4%

(2.61M)

11.0%

Female 2.5% 1.6%

(0.12M)

0.9%

Urban 24.1% 18.9%

(1.56 M)

5.0%

Rural 32.3% 26.2%

(1.17 M)

6.0%9th August 2009 50RAMPAL

NHMS3 - Adolescent Smoking Prevalence (13 to <18 years)

Overall Boys Girls

Ever smokers - Young people who have ever smoked a cigarette (even 1puff)

14.7%

(180,328)

26.2%

(162,438)

3.0%

(17,891)

Current smokers - Young people who smoke on at least one day in the last 30 days preceding the survey

8.7%

(107,154)

16.6%

(103,240)

0.7%

(3,914)

Frequent/ established smokers Young people who have smoked on at least 20 of the 30days preceding survey

3.3%

(40,172)

6.4%

(39,083)

0.18%

(1,089)

Experimental smokers - Young people who have smoked < 20days for the past 30 days & not smoked for last 7 days

1.1% 1.9% 0.2%

Triers - Young people who ever tried to smoke but stopped after only one (1) cigarette or after a few puffs

5.2% 8.3% 2%9th August 2009 51RAMPAL

10 Principal Causes of Deaths in MOH Hospitals, 2006

Septicaemia 16.87%

Heart Diseases & Diseases of Pulmonary Circulation 15.70%

Malignant Neoplasm 10.59%

Cerebrovascular Diseases 8.49%

Pneumonia 5.81%

Accidents 5.59%

Diseases of the Digestive Systems 4.47%

Certain Conditions Originating in the Perinatal Period 4.20%

Nephritis, Nephrotic Syndrome & Nephrosis 3.83%

Ill-defined conditions 3.03%9th August 2009 52RAMPAL

Total Treatment Cost for 3 Smoking Related Diseases/ Year (RM - million)

Mean Min Max

Patient 949.8 682.3 1730.6

Provider 1975.0 925.0 3257.7

Total 2924.8 1607.3 4988.3

% of GDP 0.74 0.41 1.27

% of NHE 16.49 9.06 28.12

% MOH budget 26.14 12.24 43.11

Syed Aljunid, 20059th August 2009 53RAMPAL

Factors Influencing Tobacco Use


1. Tobacco industry marketing and advertising2. Profit margin/ Sales are legal even though it kills half of its user 3. Nicotine Addiction4. Low Tobacco Tax5. Peer smoking status and influence6. Parental smoking status7. Smoking environment in Workplace and house8. Greed and Corruption9. Smuggling of tobacco products


Tobacco industry marketing, including product design, advertising, and promotional activities, is a factor influencing susceptibility to and initiation of smoking7.

Billion are being spent (?wasted).


TOBACCO INDUSTRY TARGETTED YOUNG PEOPLE( DYER C. BMJ 1998;316:1923

• RJ Reynolds Marketing Plan -1975

• “The fragile , developing self image of the young persons needs all of the support and enhancement it can get…..

• This self image enhancement effect has traditionally been a strong promotional theme for cigarette brands and should continue to be emphasised”.

• Claude Teague, assistant chief, R&D ,Reynolds 1973


TOBACCO INDUSTRY – ADVERTISMENT??


ON THE SIDE OF A SHOP



RESTAURANT



2. NICOTINE ADDICTION


Section 2: Tobacco Dependence

Mechanisms • Nicotine’s actions in the central nervous

system• Neurobiologic and physiologic effects of

tobacco dependence • Tobacco dependence and environmental

reinforcement• Symptoms of withdrawal

Mechanism of Action of Nicotine in the Central Nervous System

• Nicotine binds preferentially to nicotinic acetylcholinergic (nACh) receptors in the central nervous system; the primary is the 42 nicotinic receptor in the Ventral Tegmental Area (VTA)

• After nicotine binds to the 42 nicotinic receptor in the VTA, it results in a release of dopamine in the Nucleus Accumbens (nAcc) which is believed to be linked to reward

4 2224

42Nicotinic Receptor

Nicotine Stimulates Dopamine Release

• Nicotine activates 42 nicotinic receptors in the ventral tegmental area resulting in dopamine release at the nucleus accumbens. This may result in the short-term reward/satisfaction associated with cigarette smoking.

D

Ventral Tegmental Area

Nucleus Accumbens

Adapted from Picciotto MR, et al. Nicotine and Tob Res. 1999: Suppl 2:S121-S125.

D 42 Nicotinic ReceptorNicotine Dopamine

Reward

D

D

DAxon

1. Schroeder SA. JAMA. 2005;294:482-487. 2. Jarvis MJ. BMJ. 2004; 328:277-279.

Nicotine May Cause Up-Regulation and Desensitization of Receptors Resulting in Tolerance

• Tolerance typically develops after long-term nicotine use1

• Tolerance is related to both the up-regulation (increased number) and the desensitization of nicotine receptors in the VTA1

• A drop in nicotine level, in combination with the up-regulation and decreased sensitivity of the nicotinic receptor, can result in withdrawal symptoms and cravings1

• Smokers have the ability to self regulate nicotine intake by the frequency of cigarette consumption and the intensity of inhalation1

• In order to maintain a steady nicotine level, smokers generally titrate their smoking to achieve maximal stimulation and avoid symptoms of withdrawal and craving2

The Cycle of Nicotine Addiction

• Nicotine binding causes an increase in release of Dopamine1,2

• Dopamine gives feelings of pleasure and calmness1

• The Dopamine decrease between cigarettes leads to withdrawal symptoms of irritability and stress1

• The smoker craves Nicotine to release more Dopamine to restore pleasure and calmness1

• Competitive binding of Nicotine to nicotinic acetylcholinergic receptors causes prolonged activation, desensitization, and upregulation2

• As Nicotine levels decrease, receptors revert to an open state causing hyperexcitability leading to cravings1,2

1. Jarvis MJ. BMJ. 2004; 328:277-279. 2. Picciotto MR, et al. Nicotine and Tob Res. 1999: Suppl 2:S121-S125.

DopamineDopamine

NicotineNicotine

Tobacco Industry

• “It has been suggested that

large numbers of people will continue to smoke because they cant give it up. If they could they would do so. They can no longer be said to make an adult choice.” ( British American Tobacco 1980)

• Nicotine is the addictive agent in cigarettes ( Brown & Williamson memo from A.J.Mellman 1983)


SMOKING IN UTERO INCREASES RISK OF LATER ADDICTION ARNOLD MANN NIDA, 2004: 19 (4)


Patrick Zickler NIDA 2004; 19 (2)

SMOKING MAY BE MORE ADDICTIVE IF IT IS INITIATEDDURING ADOLESCENCE, AND EARLY EXPOSURE MAY HEIGHTEN RESPONSE TO OTHER ADDICTIVE DRUGS.

MALES AND FEMALES MAY DIFFER IN THEIR SUSCEPTIBILITYTO THESE EFFECTS


REAL PRICE OF TOBACCO TO CONSUMER – PRICE WAR


TOBACCO PRICE WAR - Decline in tobacco price

???Answer: Increase Taxes to such an extent that tobacco companies don’t think of reducing their price again.Use the money for Tobacco control activities and for Victims of Tobacco Use


PEERS SMOKING


PARENTAL SMOKING


Risk factors Crude Odds Ratio

P value Adjusted Odds Ratio

P value

Highest education achieved University/ College Secondary Primary No formal Education

1.001.61 (1.40, 1.86)1.41 (1.2, 1.65)0.98 (0.81, 1.19)

<0.001<0.0010.846

1.002.22 (1.87, 2.64)2.68 (2.18, 3.30)6.61 (4.91, 8.89)

<0.001<0.001<0.001

Friends who smoke No Yes

1.0017.95 (15.25,

21.13)<0.001

1.004.9 (4.03, 5.96) <0.001

Family who smoke No Yes

1.001.58 (1.44, 1.74) <0.000

1

1.002.20 (1.97, 4.47) <0.001

Self Esteem High Moderate Low

1.000.97 (0.88, 1.07)1.29 (1.16, 1.45)

0.565<0.001

1.000.92 (0.81, 1.04)1.31 (1.13, 1.51)

0.185<0.001


HOUSEHOLD AND WORKPLACE


GREED AND CORRUPTION


A letter from James F. Ripslinger to Sylvester Stallone dated June 14 1983

• Mr Sylvester Stallone received $500,00.00 from B&W Tobacco Corp. for B & W appearances and usage in his 5 films• Rhinestone Cowboy/ Godfather III /Rocky IV• Rambo / 50/50• ASH(http://www.ash.org.uk)


It is sad that very few

is calling for its BAN


0

10

20

30

40

50

60

70

80

90

100

40 50 60 70 80 90 100

Age (Years)

1. Doll R, et al. BMJ. 2004;328:1519–1527.

Quitting at Any Age May Increase Life Expectancy

Quitting sooner appears most beneficial

Survival At Each Age Point (%)40

35-44 Stopped Age

Results From a Study of Male Physician Smokers in the United Kingdom

Nonsmokers

Cigarette Smokers

Risk of Cardiovascular Disease (CVD) Reduced By Quitting

Smoking

• Quitting associated with – 36% reduction in odds of all-cause mortality among patients with

coronary heart disease (CHD)1

– Decreases in CVD events in cardiac patients, even in those who recently quit2

*Defined as self-reported smokers who were cotinine negative.1. Critchley JA, Capewell S. JAMA. 2003;290:86-97. 2. Twardella D et al. Eur Heart J. 2004;25:2101–2108.

0.710.64

0.44

1.00

0.00

0.20

0.40

0.60

0.80

1.00

1.20

Currently Smokes Recently Quit* FormerlySmoked

Never Smoked

Odds Ratio

COMBATTING THE PROBLEM


1. CORE DEMAND REDUCTION2. CORE SUPPLY REDUCTION


NGOs Role in tobacco control efforts should be focused on several fronts:

• Preventing people from taking up tobacco consumption;

• Promoting cessation

• Protecting non-smokers from the exposure to tobacco smoke

• Regulating tobacco products


WHO classifies interventions into two major groups, those aimed at reducing the demand for tobacco:

• Price and tax measures• Protection from exposure to second-hand tobacco

smoke• Regulation and disclosure of the contents of tobacco

products• Packaging and labeling• Education, communication, training and public

awareness-raising• Comprehensive bans and restriction on tobacco

advertising, promotion and sponsorship• Tobacco-dependence cessation measures;9th August 2009 92RAMPAL

and those aimed at reducing the supply of tobacco:

Control of Smuggling has proven to be the key supply side measure


ROLE OF NGOs IN TOBACCO CONTROL

• 1. ADVOCATIVE

• 2. COMMUNITY LEADERSHIP

• 3. EDUCATIONAL

• 4. CATALYST

• 5. TRAINING AND CAPACITY BUILDING

• 6. RESEARCH

• 7. COMPLEMENTARY ROLE


MALAYSIAN EXPERIENCE

• 1982 to 2003

• 2004 to 2009


The major events organized by Action on Smoking and Health Committee (ASH), MMA in Tobacco Control Activities

1982-2004 with the co-operation of large number of organization


1983 National workshop on smoking control 1984 Superman Campaign against smoking target at school children. About 7000 students directly participated in the campaign. All students who

participated received a superman poster, sticker, comic and a certificate.

1985 National seminar on Smoking Control. 1986 NATIONAL NO SMOKING DAY (5 Nov.1986)1987 NATIONAL NO SMOKING WEEK 1988 NATIONAL NO SMOKING WEEK1989 NATIONAL NO SMOKING WEEK 1990 NATIONAL NO SMOKING WEEK 1991 NATIONAL NO SMOKING WEEK 1992 NATIONAL NO SMOKING WEEK 1993 NATIONAL NO SMOKING WEEK 1998 INTERNATIONAL QUIT AND WIN (NO SMOKING MONTH) 2000 INTERNATIONAL QUIT AND WIN (NO SMOKING MONTH) 2002 INTERNATIONAL QUIT AND WIN (NO SMOKING MONTH) These workshop, seminar and campaign served to create awareness, bring about

change in government policy on tobacco control and highlight many different aspects of smoking control issues

2004 and 2006 INTERNATIONAL QUIT AND WIN (NO SMOKING MONTH)


PARTICPATION FROM :

MEDICAL ORGANISATIONS

GOVERNMENT DEPARTMENTS

HOSPITALS

ACADEMIC / PROFESSIONAL INSTITUTIONS

• BANKS

PRIVATE COMPANIES

•HOTELS


MMA SUBMITS MEMORENDAM TO

GOVERNMENT TO BAN SMOKING IN PUBLIC

PLACES


IMPACT: CABINET RULING BANS SMOKING IN

GOVERNMENT MEETINGS AND PLACES


LEAD ROLE :CATALYST

ASH,MMA ORGANISESWORKSHOP ON SMOKING OR

HEALTH 1983


SLIDE SHOWING WORKSHOP AND EXHIBITION “ON SMOKING OR HEALTH 9.10.1983

Dr RAMPAL


NATIONAL NO SMOKING DAY 6TH NOV 1986

ORGANISED BY ASH, MMA WITH COLLABORATION WITH

MOH AND OTHER NGO’S


ROLE: EDUCATIONAL

ASH, MMA HIGHLIGHTS HAZARDS OF

PASSIVE SMOKING


ROLE : EDUCATIONAL

ASH, MMA HIGHLIGHTS ROLE OF HEALTH

PROFESSIONALS IN TOBACCO CONTROL


WORLD NO TOBACCO DAY 1993


ROLE :ADVOCATIVE

ASH MMA WRITES TO MALAYSIAN AIRLINES TO BAN SMOKING ON LOCAL FLIGHTS


Impact Of Health Promotion And Advocacy

1982 Ban on cigarette advertisement on television and radio. No smoking is permitted in any government meetings.

1983-2002 Increase in excise duties and taxes on tobacco.1989Total ban on smoking during South East Asian Games, held in KL.1990 Ban on smoking in prisons.1991 Ban on smoking in all institutions and facilities. Ban on smoking in all cinemas in all local authorities in Malaysia The Ministry of Health declared all its hospitals and Health centres as smoke free. The D. General of Prisons has declared all prisons as smoke free. 1992 Many private sector offices, factories have declared their areas as No

Smoking Zones


Impact Of Health Promotion And Advocacy

1998 : International Quit Smoking and Win competition and National Art competition "Growing up without Tobacco" More than 945 people from all parts of Malaysia participated. This was the first time such a large number agreed to give up smoking for at least one month. The art competition was also a big success.

2000 : ASH, MMA and the Public Health Society jointly with the Ministry of Health organised the International Quit Smoking and Win competition. More than 1,155 people from all parts of Malaysia participated. ASH, MMA also organized a National Art Competition. The art competition was also a big success and several prizes were given out for both the events.

In 2002, Malaysian Government decided to establish a Health Promotion Foundation using Taxes from Tobacco and Alcohol (Sin Tax) .

1992-2003: Most federal and state departments have declared the work place as smoke free. All Government Universities and most Institutions of Higher Learning declared Smoke Free carried out smoking control activities. Smoking control activities in work place, has in last two years also significantly increased and making an impact not only in the government but also private sector. Many private firms and factories are increasingly making their workplace a smoke free zone and organising various smoking control activities.


ASH, MMA SUBMITS MEMORENDAM TO

GOVERNMENT TO BAN SMOKING IN PUBLIC

PLACES


IMPACT

• BAN ON SMOKING ON MALAYSIAN AIRLINES


IMPACT

• BAN ON SMOKING ON MALAYSIAN AIRLINES

• BAN ON SMOKING IN PUBLIC TRANSPORT

• BAN ON SMOKING IN PUBLIC


ROLES: LEAD AND CATALYST


INTERNATIONAL QUIT SMOKING AND WIN CAMPAIGN – MALAYSIA

1998, 2000, 2002 , 2004


Rules and Regulations

1. Open to the general public aged 18 and above2. Open to smokers who have smoked for a

minimum of 1 year prior to 1st May .3. Closing date for applications: 30th April 4. Entry form could be obtained from all

Ministry of Health Government Hospitals, Health Centres,

Malaysian Medical Association Secretariat, National Cancer Council and

Malaysian Heart Foundation


5. Forms appearing in the Nation Newspaper and photocopied forms were be accepted.

6. Participants were randomly selected using table of random numbers.

7. Interviews and Urine test were carried out for those short listed

8. Judges decision was Final


NATIONAL LEVEL1st. Prize : RM 3,0002nd Prize : RM 2,0003rd Prize :RM 1,00030 Consolation prizes:Air Ticket/ Hotel stays/ Hampers etc

INTERNATIONAL LEVELThe first Prize winner at the National level will have a chance to win US10,000.00 at the International Level

PRIZES


PANEL OF JUDGES

• Assoc Prof Dr Lekhraj Rampal (Chairman,Organizing Committee IQSW Malaysia,

and Chairman, ASH,MMA)• Tan Sri Dato Dr Abdul Majid, ( Deputy President, National Heart Foundation)• Dato Farid, President National Cancer Council• Dr Sallehudin (Representive, Ministry of Health

Malaysia• Dato Dr P Krishnan, President Malaysian Medical

Association


The International Quit Smoking and Win is an Global Joint event involving 75 countries and we expect 500,000 to one million participants to give up smoking for at least one month it also helps to inform the general public about harmful effects on health by tobacco consumption.


Assisted by:• Major TV Stations

• Radio

• Major Newspapers –English, Malay Chinese and Tamil language dailies


The IQSW application forms were published in the English, Malay, Chinese and Tamil Language Newspapers which had Nation-wide circulation.


IQSW 1998 POSTER9th August 2009 141RAMPAL

1998 ACTIVITIES i) International Quit Smoking and Win

Competition (Talks, Exhibitions, TV and Press Interviews) ii) National Art competition with the theme

"Growing up without Tobacco" More than 2000 people from all parts of

Malaysia participated. This was the first time such a large number agreed to give up smoking for at least one month. The art competition was also a big success.


Fig 10: International Quit Smoking And Win Campaign 1998-Malaysia9th August 2009 144RAMPAL

ROLE - ADVOCATIVE

Tobacco Advertisment Issue brought up by Dr Lekhraj Rampal, Chairman, ASH ,MMA’ and

Minister Agrees to bring up the Issue of Tobacco Advertisment to Cabinet


ROLE : ADVOCATIVE

• ASH,MMA WRITES TO MINISTRY OF HEALTH TO HAVE WARNING MESSAGES ON CIG. PACKETS


IMPACT

Malaysia enacted the control of Tobacco Product Regulations 1993 under the Food Act 1983 to discourage smoking in the

country. A number of provisions are made in the Regulations to curb smoking.

This includes areas such as cigarette accessibility to children, health warning messages and cigarette advertising.

One of the programs intended to discourage smoking is the anti-tobacco media campaign.


Fig 14: President Malaysian Medical Association and Chairman ASH Slam Tobacco Firms Over Warning Labels


DR RAMPAL


Launched by Deputy Minister of Health, Malaysia


ROLE :ADVOCATIVE

ASH MMA WRITES TO THE GOVERNMENT TO INCREASE TAX ON TOBACCO AND HAVE A SPECIAL FUND FOR TOBACCO CONTROL ACTIVITIES


Message form Prof Dr Lekhraj RampalChairman, ASH, MMA on World No Tobacco Day

31st May 2007Major TV stations and Newspapers

and again on 2 July 2007 TV 2

• TOBACCO PRICE WAR - Decline in tobacco price going in Malaysia

???Answer: Increase Taxes to such an extent that tobacco companies don’t think of reducing their price again.Use the money for Tobacco control activities and for Victims of Tobacco Use


WE CAN QUIT SMOKING

Fig 11: Bank Staff Quit As A Group During IQSW 19989th August 2009 169RAMPAL

DEPUTY MINISTER OF HEALTH QUITS SMOKING


Fig. 5: Launching of the No Smoking Week 1987 . Deputy Minister of Health. Kicks The Habit Himself (30 Years As a Smoker)


GETTING THE HEALTH PROFESSIONALS IN THE

ARMED FORCES INVOLVED


• Health professionals such as physicians, nurses, midwives, pharmacists, dentists, physiologists, chiropractors, and other health-related professionals have an enormous potential to play a key role in battling the tobacco epidemic.

• They have several roles in common and that work in unison, where one role does not substitute for another.


NGOs Roles include: Role Model:

• In your society and your communities you are expected to act on the basis of this knowledge.

• In your society and your communities your are expected to be role models for the rest of the population.


As Scientist • Tobacco control measures must be based on facts and

evidence. • Research in less programme and policy implementation

and evaluation should be encouraged as well.

• You have a duty to create awareness and educate funding and research agencies about tobacco consumption’s impact on all aspects of individual, community and social health, so that adequate funding resources for research in addressing this worldwide epidemic.


As a Leader

• Many of you have leadership positions at different levels and several considerable public trust.

• As professionals who belong to professional organizations YOU can also influence your organization to become involved in

tobacco control policy-making, and to place tobacco in the organization’s agenda.


Opinion-builder

Your role to build opinion in support of tobacco control has great potential but has been neglected by most NGOs to date.


Alliance-builder

• You can be form alliances as individuals, between societies and organizations.


Watch out for tobacco industry activities

• NGOs have a duty to denounce tobacco industry strategies aimed at hindering local, national or international tobacco control efforts.

• In addition, health professionals need to take a stand against the pervasive and negative influence of tobacco industry money in many aspects of our society.


BARRIERS TO NGOs INVOLVEMENT IN

TOBACCO CONTROL

1.Lack of knowledge and skills about tobacco and tobacco control:

2.Lack of organizational leadership

3. Continued tobacco consumption among NGOs Members


ROLE:TRAINING

HEALTH PROFESSIONALS IN SMOKING CESSATION

TECHNIQUES


PARTICIPATION IN LOCAL ANDINTERNATIONAL CONFERENCES AND FORUMS


DR PETO AT WORLD CONFERENCE IN FINLAND9th August 2009 193RAMPAL

Dr Judith Mackay at APACT Conference in Taiwan9th August 2009 195RAMPAL

MALAYSIAN HEALTH PROMOTION BOARD


YOUTH INVOLVEMENT


DEPUTY MINISTER OF YOUTH AND SPORTS LAUCHES TOBACCO CONTROL ACTIVITIES AMONGST THE YOUTH USING INTERACT AND ROTERACT CLUBS


TOBACCO FREE SPORTS

NATIONAL ART POSTER & SLOGAN COMPETITION

INTERNATIONAL QUIT SMOKING AND WIN 2002

THEME: TOBACCO FREE SPORTS


Organized by

MMA AND COMMONWEALTH MEDICAL ASSOCIATION


IMPACT ON THE MEMORENDUM GIVEN BY ASH, MMA TO THE

GOVERNMENT TO INCREASE TAXES AND USE THE MONEY FOR TOBACCO

CONTROL ACTIVITIES- SIN TAX


2005

WORLD NO TOBACCO DAYLaunched by MINISTER OF WILAYAH PERSEKTUAN

31.5.2005 AT UNIVRSITY MALAYA


WINNERS OF COMPETITION BEING GIVEN PRIZES


USING ART AND CULTURE IN TOBACCO CONTROL


NATIONAL ART COMPETITION2005

ASH, MMATHEME:

HARMFUL EFFECTS OF TOBACCO AND TOBACCO PRODUCTS – START A HEALTHY LIFESTYLE WITHOUT TOBACCO

ORGANIZED BY MMA WITH THE ASSISTANCE OF MINISTRY OF EDUCATION, HEALTH AND PRIVATE SECTOR


NATIONAL ART POSTER COMPETITION - 2005ORGANIZED BY ASH, MMA

• 1300 ENTRIES FROM ALL STATES IN MALAYSIA PARTICIPATED


JUDGES SELECTING THE WINNERS

MR VICTOR CHIN(PROFESSIONAL ARTIST)


PROF DR KRISHNA GOPALTRUSTEE NATIONAL ART MUSEUM


CHAIRMAN ASH,MMA DR RAMPAL WITH THE WINNERS9th August 2009 227RAMPAL

PLEASE ADVOCATETO EXTEND THE

EXISTING BAN TO INCLUDE


CADANGAN PERLUASAN KAWASAN LARANGAN CADANGAN PERLUASAN KAWASAN LARANGAN MEROKOKMEROKOK

Komitmen Negara terhadap FCTC - Article 8, - “Protection from exposure to tobacco smoke”

Melindungi orang awam dan warga kerja terutamanya kanak-kanak, remaja, wanita dan orang yang tidak merokok daripada bahaya asap rokok

Kementerian Kesihatan Malaysia akan memperluaskan kawasan larangan merokok meliputi :

1. Lobi Hotel

2. Tempat Kerja Tertutup (Enclosed Workplace)

3. Semua Tempat Makan (gerai, kedai, restoran dan pusat penjaja)


IN CONCLUSION: YOU AND YOUR NGOs CAN PLAY THE FOLLOWING ROLES

IN TOBACCO CONTROL

• 1. ADVOCATIVE• 2. COMMUNITY LEADERSHIP• 3. EDUCATIONAL• 4. CATALYST• 5. TRAINING AND CAPACITY BUILDING• 6. RESEARCH• 7. COMPLEMENTARY ROLE


IN CONCLUSION:

Malaysia has taken several steps forward in tobacco control.

We need to work together locally and globally to achieve –“ A Tobacco Free World”.


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