How to Fight the Tobacco EpidemicHow to Fight the
Tobacco Epidemic Presentation to Portfolio Committee on
the Tobacco Products Control Amendment Bill, 23 January 2007
C T Bolliger
Presentation to Portfolio Committee on the Tobacco Products Control
Amendment Bill, 23 January 2007C T Bolliger
History of TobaccoHistory of Tobacco A.D. 600: Maya stone carvings
1492: Columbus tobacco to Europe
16th cty: Sultan Constantinople: smokers to be quartered, or at least beheaded
1604: James I: “A Counterblaste to Tobacco” AND big revenue by tax !!!
1798: Benjamin Rush, colonial physician: condemns tobacco
19th cty: moderate consumption- pipe, cigars, chew, sniffing
1881: cigarette-rolling machine- safety matches
A.D. 600: Maya stone carvings
1492: Columbus tobacco to Europe
16th cty: Sultan Constantinople: smokers to be quartered, or at least beheaded
1604: James I: “A Counterblaste to Tobacco” AND big revenue by tax !!!
1798: Benjamin Rush, colonial physician: condemns tobacco
19th cty: moderate consumption- pipe, cigars, chew, sniffing
1881: cigarette-rolling machine- safety matches
History of TobaccoHistory of Tobacco
1906: “The Dukes” investing up to 80% of profit into advertising
20th cty: smoking epidemic
1945: cigarette dominant
1964: Luther Terry, First Surgeon General’s report
1998: EC advertising ban voted
2003: FCTC (signed by > 100 countries by June 2004, !!! ratified)
1906: “The Dukes” investing up to 80% of profit into advertising
20th cty: smoking epidemic
1945: cigarette dominant
1964: Luther Terry, First Surgeon General’s report
1998: EC advertising ban voted
2003: FCTC (signed by > 100 countries by June 2004, !!! ratified)
PrevalencePrevalence
1923 24 25 27
31 3235 36
45
51
0
10
20
30
40
50
60
% of Adults who smoke
SwedenU.S.A.South AfricaItaly U.K.JapanFranceGermanyRussiaSerbiaTurkey
1923 24 25 27
31 3235 36
45
51
0
10
20
30
40
50
60
% of Adults who smoke
SwedenU.S.A.South AfricaItaly U.K.JapanFranceGermanyRussiaSerbiaTurkey
Sources: WHO, National Centre for Health Statistics, Japan Tobacco Inc.,Comité Français d’Éducation pour la Santé, Serbian Ministry of Health, The World Bank, SADHS,
Advertising banned in SA since 2001
Advertising banned in SA since 2001
Switzerland (15-74yrs): 33%
latest (2002): 30.5%
15-24 yo.: 37.4%
South Africa (>18yrs, SADHS 98) : 24%
latest (2004): 22%
Switzerland (15-74yrs): 33%
latest (2002): 30.5%
15-24 yo.: 37.4%
South Africa (>18yrs, SADHS 98) : 24%
latest (2004): 22%
Cigarette Sales and Tax Revenue (CH)
0
200
400
600
800
1000
1200
1400
1600
1800
2000
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Mio Cig.packsMio SFr
Cigarette prices and consumption (S.A.) C van Waalbeek
Cigarette prices and consumption (S.A.) C van Waalbeek
0
200
400
600
800
100019
60
1964
1968
1972
1976
1980
1984
1988
1992
1996
2000
Rea
l p
rice
per
pac
k o
f 20
(
in c
on
stan
t 20
00 c
ents
)
0
500
1000
1500
2000
2500
Cig
aret
te c
on
sum
pti
on
(m
illi
on
s o
f p
acks
)
Real price of cigarettes Consumption of cigarettes
Composition of the retail price of cigarettes (S.A.) C van Walbeek
Composition of the retail price of cigarettes (S.A.) C van Walbeek
0
100
200
300
400
500
600
700
800
900
10001
96
1
19
63
19
65
19
67
19
69
19
71
19
73
19
75
19
77
19
79
19
81
19
83
19
85
19
87
19
89
19
91
19
93
19
95
19
97
19
99
20
01
20
03
Cen
ts/p
ack
(co
nst
ant
2000
pri
ces)
Industry price Excise tax Sales tax (GST/VAT)
S.A.government‘s achievements
S.A.government‘s achievements
Advertising banPrice increaseRestaurants
Advertising banPrice increaseRestaurants
Projected annual tobacco-related deaths
Projected annual tobacco-related deaths
Year Total 1.World 3.World
1950 300.000 300.000 -
1965 1.000.000 900.000 100.000
1975 1.500.000 1.300.000 200.000
1995 3.000.000 2.000.000 1.000.000
2000 3.500.000 2.400.000 1.100.000
2025 10.000.000 3.000.000 7.000.000Mackay JL. Tuber Lung Dis 1994;75:8-24
Year Total 1.World 3.World
1950 300.000 300.000 -
1965 1.000.000 900.000 100.000
1975 1.500.000 1.300.000 200.000
1995 3.000.000 2.000.000 1.000.000
2000 3.500.000 2.400.000 1.100.000
2025 10.000.000 3.000.000 7.000.000Mackay JL. Tuber Lung Dis 1994;75:8-24
Perceived risks of CAD and Cancer in Smokers
Perceived risks of CAD and Cancer in Smokers
MI Cancer
Current smokers 29% 40%
40 cig/day 39% 49%
MI Cancer
Current smokers 29% 40%
40 cig/day 39% 49%Ayanian JZ. JAMA 1999;281:1019-21
Never smokedregularly
Current ciga-rette smokers 80%
59%
7.5 years
33%
12%
100
80
60
40
20
0
% A
live
40 55 70 85 100Age
(Doll R., BMJ 1994; 309:901-11. 35 539 doctors x 40 years)
Never smoked regularlyFormer smokersContinuing cigarette smokers
Former smokersstopped 35 - 44
Former smokersstopped 45 - 54
Former smokersstoped 55 - 64
Former smokersstopped > 65
100
80
60
40
20
0
% A
live
100
80
60
40
20
0
% A
live
40 55 70 85 100 40 55 70 85 100Age Age
50% of long-term smokers die from their
habit
50% of long-term smokers die from their
habitDoll R. BMJ 1994
Risk factors for MIRisk factors for MI
Yusuf S, Lancet 2004;364:937-52
Smoking is the most important preventable
cause of disease
Smoking is the most important preventable
cause of disease
Law MR. BMB 1996;52:22
Effect of number of cigarettes smoked at home
Effect of number of cigarettes smoked at home
0.8
1
1.2
1.4
1.6
1.8
2
Recurrent cough Influenza Bronchitis
0.8
1
1.2
1.4
1.6
1.8
2
Recurrent cough Influenza Bronchitis
1 1 - 10 11 - 20 > 20
Risk factor
Milk Causes
Cancer !Milk CausesCancer !
Desired nicotine actionsDesired nicotine actions Arousal Relaxation (in stress) Improved mood Increased concentration Increased vigilance Shorter reaction time Weight control Regular bowel movements
Arousal Relaxation (in stress) Improved mood Increased concentration Increased vigilance Shorter reaction time Weight control Regular bowel movements
Effects of Nicotine on the BrainEffects of Nicotine on the BrainImproves mood and influences MemoryImproves mood and influences MemoryEffects of Nicotine on the BrainEffects of Nicotine on the BrainImproves mood and influences MemoryImproves mood and influences Memory
Frontal brain: steers behaviour, remembers after years that nicotine triggers feeling of well-beingt.
Nucleus Accumbens: responsible for feeling of well-being. Nerve cells secret mainly dopamine
Hippocampus: stores memories in cooperation with frontal brain.
Amygdala: Emotions are processed.
Nicotine withdrawal symptoms (DSM-III)Nicotine withdrawal symptoms (DSM-III) Craving for tobacco Irritability Anxiety Difficulty concentrating Restlessness Headaches Drowsiness GI tract disturbances
Craving for tobacco Irritability Anxiety Difficulty concentrating Restlessness Headaches Drowsiness GI tract disturbances
How to quit? Most smokers need
professional help
How to quit? Most smokers need
professional help
National Quitline: 011 720 3145GP Smoking cessation specialistSmoking cessation Clinic
Faculty of Health Sciences,U.S.: 021 938 9423
National Quitline: 011 720 3145GP Smoking cessation specialistSmoking cessation Clinic
Faculty of Health Sciences,U.S.: 021 938 9423
The 5 A’sThe 5 A’s
Ask Smoker? Advise Quit! Assess Willing? Assist Aid! Arrange Follow-up!
Ask Smoker? Advise Quit! Assess Willing? Assist Aid! Arrange Follow-up!
Practical smoking cessationPractical smoking cessation
Screening visit: phone, computer? (motivation?!)
Initial interview GP/ nurse (day 0; 40’ - 1 h): Info about withdrawal symptoms Coping strategies Change of life style Pharmaceutical Aids? (+ 3/12) Nonsmoker at once
Intensive follow-up (p.e. weeks 1, 2, 4, 8, 12, 16, 20, 26, 52)
Occasionally intensive group therapy
Screening visit: phone, computer? (motivation?!)
Initial interview GP/ nurse (day 0; 40’ - 1 h): Info about withdrawal symptoms Coping strategies Change of life style Pharmaceutical Aids? (+ 3/12) Nonsmoker at once
Intensive follow-up (p.e. weeks 1, 2, 4, 8, 12, 16, 20, 26, 52)
Occasionally intensive group therapy
Nicotine replacement therapy
Nicotine replacement therapy
Patch (15 - 25 mg; 16h or 24 h) Chewing gum (2 or 4 mg) Mouth spray (1mg/actuation) Nasal spray (0.5 mg / puff) Inhaler (13 g / puffs; 80 puffs
1 mg = 1 Cig.) Lozenges (1mg) Sublingual tablets (2 mg)
Patch (15 - 25 mg; 16h or 24 h) Chewing gum (2 or 4 mg) Mouth spray (1mg/actuation) Nasal spray (0.5 mg / puff) Inhaler (13 g / puffs; 80 puffs
1 mg = 1 Cig.) Lozenges (1mg) Sublingual tablets (2 mg)
~
Ab
stai
ner
s (%
)100
80
60
40
20
0
N = 145
n = 144
Active
Placebo
TØnnesen NEJM 1991, 325:311TØnnesen NEJM 1991, 325:311
0 1 3 6 12 26 52
30 20 10Patch size cm2
Weeks
Continuous Abstinence during Follow-Up
Continuous Abstinence during Follow-Up
Intent to treat population32
2521
1813 11
05
101520253035
Weeks 4 - 12 Weeks 4 - 26 Weeks 4 - 52
% s
ub
ject
s ab
stin
ent
Zyban
Placebo
Intent to treat population32
2521
1813 11
05
101520253035
Weeks 4 - 12 Weeks 4 - 26 Weeks 4 - 52
% s
ub
ject
s ab
stin
ent
Zyban
Placebo
* **
** P=0.002; OR 2.19; 95% Cl 1.29, 3.86
P=<0.001; OR 2.34; 95% Cl 1.43, 3.98*
p=<0.001, OR 2.24, 95% CI 1.45, 3.56
Take home message:Take home message:
For the doctor Smoking is highly addictive (Nicotine) Smokers underestimate health risk: 50% will
be killed long-term Smokers need professional help to quit Pharmaceutical aids double success rate
For the politician S.A.: so far very good job with legislation Tabacco companies not to be underestimated Tobacco Products Control Amendment Bill
needs endorsement to achieve further reduction in tobacco consumption
For the doctor Smoking is highly addictive (Nicotine) Smokers underestimate health risk: 50% will
be killed long-term Smokers need professional help to quit Pharmaceutical aids double success rate
For the politician S.A.: so far very good job with legislation Tabacco companies not to be underestimated Tobacco Products Control Amendment Bill
needs endorsement to achieve further reduction in tobacco consumption
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