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