TOBACCO CONTROL

Kuswandewi, Nita Arisanti, Dadi

S Argadiredja
Department of Public Health
FMUP
Epidemiology

The tobacco atlas-WHO-2002

 Tobacco Consumption in Indonesia
Contribution of Ten Countries with The Greatest Smokers of The World`s

Adapted: WHO report on the global tobacco epidemic, 2008

 The Five Countries with The Largest Tobacco
Consumption (Billion Sticks)

Adapted: Bunga Rampai Fakta tembakau: Permasalahannya di Indonesia

Tahun 2009
Smokers in Indonesia ( Riskesdas 2007)

smokers

6%
24% everyday
not everyday
ex
67% 3%
not smoke
Non smokers
 Prevalence of Tobacco Consumption in
Indonesia
Prevalence of smoking population aged > 15 years by sex in
Indonesia.

Source: Survei Sosial Ekonomi (Susenas) tahun 1995, 2001, 2004, dan Riskesdas 2007
Adapted: Bunga Rampai Fakta tembakau: Permasalahannya di Indonesia Tahun 2009
Percentage of smokers (groups of age)

35 32.4 31.8
30.2
30 29 28.8 27.8
25

20
17.3
15

10

5
0.7
0
10'-14 15'-24 25'-34 35'-44 45'-54 55'-64 65'-74 75+
Everyday smokers

• Male : 45 %
• Female : 3 %

• Urban : 21.2 %
• Rural : 25.3 %
• Smokers : 29.2 %
– M : 55.7 %
– F : 4.4 %
– Age 10 – 14 : 2.0 %
• No of cigarettes / day: 12 ( 8.5 – 18.5)
– M : 11.7 %
– F : 15.7 %
– Age 10 – 14 : 10 %
• Prevalence smoking in the house with
member of family : 85.4 %
Why TOBACCO ??
More than
4000
chemicals
have been
identified
in tobacco
smoke.
• Harmful  agent of harm
• Cause of death
– Responsible for 1 in 5 death (USA)
– Reduce life expectancy : 12 years
– Major killer of middle age
– Cause of 80 % cases of CHD
– Each year :
• Cancer deaths : 155,000
• Cardiovascular deaths : 122,000
• Chronic lung diseases deaths ;
72,000
• Others : 81,000
Diseases caused by tobacco
 Why tobacco control?
• Illnesses caused by tobacco are completely
preventable
• Tobacco control:
A range of supply, demand and harm
reduction strategies that aim to improve the
health of a population by eliminating or
reducing their consumption of tobacco
products and exposure to tobacco smoke
Consequences of Tobacco-Use:
Preventable Causes of Death

Smoking 400,000

Accidents 94,000

2nd Hand Smoke 38,000

Alcohol 45,000

HIV/AIDS 32,600

Suicide 31,000

Homicide 21,000

Drugs 14,200
 DISEASE BURDEN
Active Tobacco Use
• Tobacco is the major preventable cause of
death in many parts of the world.
• Related with CV, lung disease, and cancer
• Have greater risk of developing, lung ca, heart
disease, stroke, emphysema, lips Ca
• Woman who smoke more risk than man
RISKS of Cigarette smoking
• ACUTE: shortness of breath, asthma
exacerbation,impotence, infertility, increased
serum carbon monoxide

• LONG TERM: heart attack, stroke, lung and

other cancers (larynx, oral cavity, esophagus,
pancreas, bladder, cervix, leukemia) COPD
• ENVIRONMENTAL: increased lung cancer in
spouse and children, higher rates of children
smokers, increased SIDs, asthma, middle ear
infection and respiratory diseases in children
of smokers
Passive smoking
• Hirayama(1981)woman showed a significantly
increased risk of dying from lung cancer despite
never having smoked a cigarette.
• Now smoking can also give rise to other
potentially fatal disease as heart disease and
stroke.
• Children sudden infant death syndrome (SIDS).
DEATH FROM TOBACCO USED
• 650 million will eventually be killed by
tobacco.
• 50%of half of all lifetime users die in middle
age( 35-69)
• Every day 13.000 people die from tobacco
• In 2000 smokers were 1,2 billion.
• In 2025 more than 1,7 billon.
Cumulative Tobacco-related Deaths,
2005–2030

Adapted: WHO report on the global tobacco epidemic, 2008

 Tobacco Kills More Americans Each Year Than Alcohol,
Cocaine, Crack, Heroin, Homicide, Suicide, Car Accidents,
Fires and AIDS combined:

(Chart of health effects- to be scanned in)

 TOBACCO CONSUMPTION
• Children and young people start smoking
from curiosity, the desire to look grown up,
risk taking, rebellion, peer pressure, weight
control.
• Continuation is largely fuelled by addiction to
nicotine
• Reinforced tobacco use include social and
psychological pressure, lack of knowledge
and difficulty in quitting.
• Now about 1070 million males and 230 million
females in the world  smoke
• Tobacco company produce 7 million tons
of tobacco annually.
 YOUTH

• Nearly ¼ of young smokers began at<10

• Serious consequences appear later in adulthood
• Addiction to nicotine occurs faster in young smokers
• The risks of developing tobacco-related diseases are
greater the younger one starts to smoke
Global youth tobacco
survey
• The highest youth smoking rates:
central and eastern Europe, western
pacific islands
• 25% of students having smoked their
first cigarette before the age of 10
• Most current smokers want to stop,
already tried to quit.
• Exposure to advertising is high (75%)
• Only 50% the students have been
taught in school about the danger of
smoking.
• In 1/3 survey countries girls are
smoking
 ADULT MALE
• Most of smokers are male; 1/3 (300 million) in
China.
• Higher rate tobacco used : Cambodia,
Djibouti, Indonesia, Myanmar, Vietnam, PNG
• Becoming a habit of poorer and less educated
people
 ADULT FEMALE
• 22%in developed countries and 9% in developing
countries smoke tobacco (230 million)
- Higher rates in Guinea,Myanmar,PNG
- Next 30 years  How to prevent a rise of
smoking among girls and woman especially in
Asia.
 THE SOCIAL AND ECONOMIC COST OF
TOBACCO USE
• The cost to individual and family
– loss of money spent on buying tobacco
– loss of income through illness and premature death.
– health care cost
– The cost of the time spent by other family members
looking after smokers or taking them to hospital
– The cost of illness or death in family members exposed to
passive smoke
– Higher health insurance premium
– Miscellaneous costs  fire risk
World bank estimates that the gross cost
of health care attributed to the extra health
needs of smokers can range from 0,1%-1,1 %
of gross domestic product in high income
countries.
 THE SOCIAL.........CONT
• The cost for government, employers, and
environment:
– social, welfare, and health care cost.
– loss of foreign exchange in importing cigarettes.
– higher cost of employers
– the cost of damage and fires
– Deforestation
– Lost of arable land that can be used to grow food
 Average Household Expenditure on
Tobacco in Indonesia, 2003 - 2006

Source: BPS 2003 – 2006

Adapted: Bunga Rampai Fakta tembakau: Permasalahannya di Indonesia Tahun 2009
 Proportion of Household Expenditure on
Tobacco Among The Poorest in Indonesia, 2003 -
2006

Source: BPS 2007

SELECTED PROGRAMME INTERVENTION FOR
TOBACCO CONTROL

• Delivery of school based tobacco prevention

programmes.
• Development of youth peer leader and network,
• Treatment to stop smoking and support
programmes.
• Implementation of by law against smoking in public
building.
• Creation of smoke free work place.
• Development of training programme and resources
for practitioner
• Development of tobacco control web sites.
 SELECTED PROGRAMME INTERVENTION
FOR TOBACCO CONTROL
1. Prevention
2. Cessation
3. Protection
4. Community mobilization
 PREVENTION
• Schools are an ideal setting for tobacco control
interventions.
– 1 billion of 6 billion population of the world are enrolled in
schools
– 80% of children in developing world now enroll in school,
and 60% complete at least four years.
– Teachers = 4 times health workers
• In school based programmes there is partnership
b/w health and education sectors.
• Involvement of students in policy and programme
development, implementation and evaluation.
 AN EFFECTIVE TOBACCO FREE SCHOOL
POLICY.
• Begin with a rationale for preventing and reducing
tobacco use.
• Require coordination b/w health and educational
authorities at local level.
• Enumerates procedures for communicating the
policy to students, school faculty, staffs, visitors, and
community members.
• Includes interventions to raise awareness
of the effects and consequences of tobacco use
• Prohibits tobacco use by students, faculty, parents
and visitors.
 AN EFFECTIVE..............CONT
• Totally bans tobacco advertising in school
building, surrounding and other school property.
• Prohibits the sale or trade of tobacco products on
school, property.
• Prohibits tobacco company sponsorship
• Prevent tobacco use be provided at school,
integrated in the school curriculum.
• Shows teachers, student leaders, how to implement
tobacco use prevention
 AN EFFECTIVE.............CONT.
• Access to help for quitting smoking.
• Specifies mechanisms for enforcing the policy
• Determines methods to monitor progress and
evaluate impacts.
• Designates one or more individuals or a
committee to oversee the policy’s
implementation and evaluation.
 CESSATION
• Tobacco cessation programmes helping
smokers to quit can get significant health and
benefits o individuals and societies.
• There are several behavioral and
pharmacological intervention for cessation
• GYTS ( WHO+CDC)programmes for young
people and school age
 Assessment of Smokers
• Stage of readiness to quit/ motivation
• Level of nicotine dependence
• Smoking rate > 25 sticks per day
• Smoking within 30 minutes of awakening
• Previous quit attempts
• Smoking architecture
• Smoking log/ diary
• Psychiatric comorbidity
 PROTECTION
• Promoting smoke-free environments;
- Needed to protect the health of non-smoker.
- Smoking ban in public places lead to:
Better health for non smokers and smokers.
- Some strategies are :
1. fostering awareness of the various
motivational factors of woman.
2. including media literacy skills in relations
to tobacco advertising.
 PROTECTION..............CONT
3. broadening the tobacco control network
to include organizations concern with
woman’s right and urging the woman’s
organizations to refrain from accepting
tobacco sponsorship.
4. asking leading woman to speak up against
deceitful marketing practices of the tobacco
industry.
 COMMUNITY MOBILIZATION.
• The individual and the community;
– it is successful only when different sectors and group work
in partnership promote a reduction in tobacco use.
– national health programmes are intended to reach out to
people.
– if more than one person in group or community picks up
the idea- greater likelihood that larger group or
community will be influenced.
– how families, natural groups process the information
received affects any changes in their attitude and
behavior. A message can be lost on a group where the
dominant attitude tends to dismiss it.
 THE IMPORTANCE OF MILIEU
• The prevailing attitude or milieu then influence
how each person responds to message from given
programme.
• Change in milieu can occur at the community level
as well as at the global level
• Rather than waiting for such changes to occur
spontaneously, planners should aim deliberately to
influence social attitudes.
BRINGING ABOUT CHANGES IN MILIEU
• Tobacco control efforts should aim to changes
attitudes and habits in the community, focusing on
the ways to make it more aware and interested in
tobacco control.
• Influential members of community should be
identified and initially targeted.
• Beside influence individuals, should determine also
sub groups.
• In smaller and define setting like school and
workplace direct outreach efforts yield good
result.
 OUTREACH OR DIRECT CONTACT
• To reach the broader, more difficult
communities, several intensive visits or
remote means are needed
• A facilitator can considerably enhance
effectiveness  candidates for working
directly with communities include ;
1) health workers, 2) field staff 3)teachers
4) young people group 5) trade union 6)
community based organization.
 WHAT SHOULD COMMUNITIES TRY TO
ACHIEVE
• Understanding of the full range, and concern about
the extent of harm caused by tobacco.
• Attractiveness/unattractiveness of the image of
tobacco use and user.
• Understanding of, and resistance to, overt
and covert promotion of tobacco use by the industry
and by others.
• Respect and concern for clean, uncontaminated
and pleasant environment.
 WHAT SHOULD.............CONT
• Encouragement and support of those who
still use tobacco to quit or continually reduce tobacco
use.
• Pros and cons identified by smokers for
smoking.
• Ease of access to, acceptability and affordability of
tobacco products at community level.
• Advocacy for the establishment and enforcement of
good public health policies in the field of tobacco.
 W.H.O FCTC
The WHO Framework Convention on Tobacco
Control (WHO FCTC)
Developed in response to the current
globalization of the tobacco epidemic
Objectives of convention and its protocols is
to protect present and future generations from the
devastating health, social, environmental and economic
consequences of tobacco consumption and exposure to
tobacco smoke.
 MEASURES
• Price and tax measures
• Non price measures
– Protection from exposures to tobacco smoke
– Regulation of the content of tobacco product.
– Regulation of tobacco product disclosures.
– Packaging and labeling of tobacco product.
– Education, communication, training, public awareness
– Tobacco advertising, promotion and sponsorship.
– Demand reduction measures concerning tobacco
dependence and cessation.
 FCTC
• FCTC open for signing 16-22 June 2003 in
Geneva, and 30 June 2003– 29 June 2004
in New York
• FCTC has 38 articles
• FCTC was developed in response to the globalization of the
tobacco epidemic
• FCTC has 9 parts and 38 articles
Framework Convention on Tobacco
Control (FCTC)
THANK YOU