Tobacco Epidemiology

Is Tobacco Epidemiology a Public Health emergency ?

 Yes

Because there is a lag of several years between when

people start using tobacco and when their health suffers,
the epidemic of disease and death has just begun.
 Global Statistics
• There are more than one billion smokers in the world.

• Globally, use of tobacco products is increasing,

although it is decreasing in high-income countries.

• Almost half of the world's children breathe air

polluted by tobacco smoke.

• Tobacco use kills 5.4 million people a year –

An average of one person every six seconds –
One in 10 adult deaths worldwide
5.8 trillion cigarettes smoked
in 2014 • More than 80% of the world's smokers live in low- and middle-
income countries.

• It is a risk factor for six of the eight leading causes of deaths in

the world.
 7589

5746

3686
3014

1411 1290

Out of eight diseases, six are related to tobacco deaths.

In total 26556 millions deaths of which 5395 (20.31%) were related to Tobacco use. It is
1.41 times more than HIV/AIDS and Diarrheal diseases (n=3820).
In Nepal, more than 25,000 people die every year due to diseases caused by
excessive use of tobacco. Nepal imports tobacco products worth Rs 28 billion
annually.
 Projected Deaths ,1950-2050
600 30 millions deaths can be
prevented
520
500 180 millions deaths can be
500
prevented
20 millions deaths can be
400 prevented in young adults
340
Millions

300

220
200
190

100
60
10
0
Baseline Adult consumption reduce by Young Adults comsumption
50% reduce by 50%
1950-2000 1990-2000 by 2025 2050
Nearly two third of Smokers Live just in 10
countries
 Disease causedby smoking &
secondhand smoking

• Each year 600,000 deaths per year

Projected Premature Deaths due to Tobacco Use
Tobacco Statistics of Nepal :
Current Tobacco Smoking among 15 years and
above population in Nepal (2000-2025)
42
40.2
43.9 37.5
36 34.9
32.6 31.3
28.8 30.3
27.5
25.1 23.8
20.3
14
9.8
6.9
5

2000 2005 2010 2015 2020 2025

Male Female Total
Tobacco Statistics of Nepal :
Current Daily Tobacco Smoking among 15 years
and above population in Nepal (2000-2025)
33.3

27.3

23.3
21.5 20.6
18.8
18.5
15
10.5
30.5 7.3 7.5
29.2 27.4 5.7
25.5 23.8 22.6

2000 2005 2010 2015 2020 2025

Male Female Total
Global Youth Tobacco Survey,2011
24.6

22
20.4
19.1 18.6
16.4 16.2 16.4
14.1 13.9

10

5.9 5.5

3.1
0.8

Ever smoked Current Any Current Cigarette Current Other Never Smokers
cigarettes Tobacco Users Smokers Tobacco Users Susceptible to Start
Smoking in the Next
Male Female Total Year
 Global Health Professional Students Survey ,2011

60
52.6
50 46.7
42.2
40 36.2
35.1 33.6
29.2 28.5
30
%

22.5
19.4 20.1
20 17.6 18.1
15.2

10
3.2
1.2
0
Ever smoked cigarettes Ever Used any form of Current Cigarette Smokers Current Other Tobacco
tobacco other than Users
cigarttes
Dental Medicine Nursing Pharmacy
 Implementing tobacco control
Governments use the tobacco control measures in the
WHO Framework Convention on Tobacco Control (WHO
FCTC) to reduce the prevalence of tobacco use and
exposure to tobacco smoke.

By implementing these measures, governments reduce the

heavy burden of disease and death that is attributable to
tobacco use or exposure.
WHO- Framework Convention on Tobacco
Control
• Unanimously adopted at the Fifty-sixth(56) World
Health Assembly in May 2003 by 191 nations
including Nepal.
• The FCTC is the world’s first public health treaty
on tobacco control.
• Blueprint for the global response to the pandemic
of tobacco-induced deaths and diseases
• Nepal : 3 Dec 2003 and ratified parliament on
7 Nov 2006
FCTC deals Tobacco control strategies for public
policies Such as
-Adopt tax and price measures to reduce tobacco
consumption
- Ban tobacco advertising, promotion and sponsorship
- Create smoke-free work and public spaces
- Put prominent health warnings on tobacco packages
Combat illicit trade in tobacco products.
•11 Parts and 38 articles (May 1999)
•Articles 6-14 related to Price and tax measures to reduce the demand for
tobacco,
Articles 15-17 related to illicit trade, Sales to and by minors ,Provision of
support for economically viable alternative activities
 Framework Convention on Tobacco
Control(FCTC)
• 11 Parts and 38 articles (May 1999)
• Signed by Nepal 3 Dec. 2003 and ratified FCTC in 7 Nov. 2006
The core demand reduction provisions in the WHO FCTC are contained in
articles 6-14:

• Price and tax measures to reduce the demand for tobacco

• Non-price measures to reduce the demand for tobacco, namely:

ƒProtection from exposure to tobacco smoke;
ƒRegulation of the contents of tobacco products;
ƒRegulation of tobacco product disclosures;
ƒPackaging and labelling of tobacco products;
ƒEducation, communication, training and public awareness;
ƒTobacco advertising, promotion and sponsorship; and,
ƒDemand reduction measures concerning tobacco dependence and
cessation
• Article 15-17 (here, FCTC aims to close tobacco company & give
alternative occupation to them)
• illicit & counterfeit trade
• Sales to and by minors
• Provision of support for economically viable alternative activities

• (Nepal recently awarded in dubai conference for warning about

danger of tobacco products in packets.)
MPOWER Policy, 2008
Also called Technical policy 2008,supports FCTC.A
technical package of six evidence-based tobacco
control measures to reduce tobacco use and save live.

Magnitude and
pattern of tobacco use
 Current State of Policy-Nepal

• Tobacco Product Control and Regulatory Act

2011,
• Directive for Printing and Labeling of Warning
Message and Picture in the Box, Packet,
Wrapper, Carton, Parcel and Packaging of
Tobacco Product, 2011
• Tobacco Product Control and Regulatory
Rule 2012
This is Roadmap to Tobacco Control Legislation
 Major features of the act are:
• Smoking and tobacco use ban in public places, work places
and public transportation
• Pictorial health warning on the 75% area of the cigarette and
other tobacco products packet
• Complete Tobacco Advertising, Promotion and Sponsorship
(TAPS) Ban
• Ban on free distribution and point of sale display
• Sales ban to children under 18 years and pregnant women,
• Sales ban within the span of 100 meter distance from
educational and health institutions,
• Child welfare homes, child care centers, elders’ care home,
and
• Provision of health tax fund from tobacco products
 What we did ?
• Smoke Free Places: Smoking is prohibited in a specified list of public places,
which includes most workplaces and public places. However, the law allows
managers of airports, prisons and hotels to designate smoking areas..
• Tobacco Advertising, Promotion and Sponsorship: There is a ban on most
forms of tobacco advertising . There are some restrictions on tobacco
sponsorship and the publicity of such sponsorship. FCTC Art. 5.3 provisions,
which will take effect at a date set by the Ministry.
• Tobacco Packaging and Labeling: Health warnings are composed of both
pictures and text and cover 75 percent of the upper front, upper back, and
two sides of smoked tobacco product packaging and the upper front, upper
back, and lids (where appropriate) of smokeless tobacco product packaging.
(90% - effective May 2015)

Article 5.3
on the protection of public health policies with respect to tobacco control
from commercial and other vested interests of the tobacco industry
 Burden of Tobacco
• The costs of tobacco use are measured : disease suffering and family distress.

• Economies also suffer: increased health-care costs and decreased productivity

Components related to economics

• Taxes, revenues and illicit trade (a complicated tax structure or a weak tax
administration)

• Tobacco control and employment in agriculture and manufacturing sector

• Taxes and the poor ( high tax means raise the price of tobacco and more money to
buy cigarettes )
Example : Household and Health Expenditure
• Many studies have shown that in the poorest
households in some low- and middle-income
countries, more than 10% of total household
expenditure is on tobacco.

• Non-communicable diseases which cause

prolonged sickness are responsible for four
out of five deaths in China, and absorb about
70 percent of the nation’s health spending.
the poorest households in some low- and middle-income countries,
more than 10% of total household expenditure is on tobacco.
Watching and countering the industry
The tobacco industry as disease vector
Tobacco company is big

Who are their targets ?

Children
Adolescent
Young adult
Women
 Intervention Program –Raise Tax

- Higher tobacco taxes could prevent 3 million tobacco deaths by 2030 among
smokers alive today.
 Tobacco Tax
• International Standard – more than 66%
• Nepal – 28% of the price of popular brand
(2009/10), 35% - 2013/14
• Excise Duty increased in Tobacco and Nepal on
cigarettes (9% to 15%), alcohol & Beer (10.5%
to 15%)- 2013/14(2070/71)
Government collected Rs 9.07 billion in revenue from
tobacco products in the fiscal year 2013/14. Of them, Rs
5.36 billion was excise tax, Rs 1.68 VAT and Rs 2.03 billion
income tax. In the current fiscal year, Rs 400 million was
allocated to the Health Tax Fund (0.44% of total revenue).
Quitting tobacco
Why to quit Smoking ?
http://whyquit.com/pr/041210.html
Chemicals In A Cigarette
 Quitting tobacco
• Quitting tobacco is not easy as tobacco
dependence is a cluster of behavioral,
cognitive and physiological phenomena
•Very few tobacco users can successfully quit
the habit in their first attempt.

• From quit lines to counseling to prescription

medicines, there are numerous effective ways
to quit.
 Nicotine dependence
• It is an addiction to tobacco
products caused by the drug
nicotine.
• Nicotine dependence means
you can't stop using the
substance, even though it's
causing you harm.
• Also called tobacco
dependence
 Five Major Steps to Intervention
(The "5 A's”)
• Ask - Identify and document tobacco use status for every
patient at every visit. (You may wish to develop your own vital
signs sticker).
• Advise - In a clear, strong, and personalized manner, urge
every tobacco user to quit.
• Assess - Is the tobacco user willing to make a quit attempt at
this time?
• Assist - For the patient willing to make a quit attempt, use
counseling and pharmacotherapy to help him or her quit.
• Arrange - Schedule follow-up contact, in person or by
telephone, preferably within the first week after the quit date
• Take vitals on follow up after 1 week= you can tell how vital
signs changes in a week( smoking cessation effect). If no
changes = other alternatives.
Fagerström Test for Nicotine Dependence
The FTND was widely accepted and statistically valid tools employed in tobacco
addiction research due to its ease of understanding and rapidity of application.

The FTND is a standard instrument for assessing the intensity of physical addiction to
nicotine.
ITEMS
Q1.How soon after waking do you smoke your first cigarette?(3=within 5 minutes, 2=within 6-30 minutes,
3=within 31-60 minutes;1=after 60 minutes)

Q2.Do you find it difficult to refrain from smoking in places where it is forbidden? (1=Yes/ 0= No)

Q3.Which cigarette would you hate most to give up? (0= any other cigarette of day, 1= first cigarette of
day)

Q4. How many cigarettes per day do you smoke? (0=10 or less,1=11-20, 2=21-30, 3=31 or more )

Q5. Do you smoke more during the first hours after waking than during the rest of the day? (1=Yes/ 0= No)

Q6.Do you smoke even when you are ill enough to be in bed most of the day? (1=Yes/ 0= No)
 SCORE NICOTINE DEPENDENCE

• 0 No Dependence
• 1-2Low Dependence
• 3-5Moderately Dependent
• 6-8Highly Dependent
• 9-10Very Dependent
• This test is not a biological marker , for biological
marker : Quotinine test(not available)
Thank You