Healthwise

The Tobacco Epidemic

World No-Tobacco day falls today:

Walter LADDUWAHETTY

The Director General of the World Health Organization in his address to the International Conference on Tobacco and Health held in Japan some years ago referred to the harmful effects of tobacco on health as “the tobacco epidemic” and WHO’s call for global action against “man-made health disaster.” In calling attention to this man-made disaster, which has reached epidemic proportions the head of the WHO, was certainly not over stating the gigantic proportions of the problem.

Statistics show that four million deaths occur every year or eleven thousand per day. All these deaths are caused not by natural disasters but are all man-made. The DG pointed out that “a cigarette is the only consumer product which when used as desired kills its consumer.”

Conscious of the magnitude of the problem, ten years ago the WHO called for an international effort to work on the Framework Convention on Tobacco Control. More than one hundred countries, over thirty International NGO’s, some 123 UN agencies and the European Union joined hands in the massive exercise to call for strict international controls to stem the tobacco tide, for tobacco will kill more people than malaria, tuberculosis and natural and childhood conditions combined.

Scientific evidence leaves no doubt that tobacco kills. Studies done over the years in the United States, China and India unequivocally pointout that tobacco is a killerbeedis and such like smokes are even worse than cigarettes.

A recent International Atomic Energy Agency document having done a study in Sri Lanka pertaining to Cancer observed that tobacco control is the major area of cancer prevention. While cancer can affect people of all ages and backgrounds in all communities, young and old, rich and poor the linkage between cancer and other factors like genetic susceptibility, lifestyle factors, unhealthy diet and the “increased prevalence of smoking” are too well known. Cancer itself is a global problem the prevalence of which will increase dramatically over the next decade especially in the developing world. In the year 2000 there were over 10 million new cancer cases with 6.2 million deaths and 22.4 million persons living with cancer. By 2020 it is estimated there will be 20 million people per year afflicted with cancer. One of the many factors for this unfortunate situation is none other than smoking. Cancer too is now referred to as an epidemic. The sad fact is that almost one third of these cases can be prevented. Herein lies the linkage between the avoidance of smoking and the incidence of cancer.

The problem has wide ramifications and the approach must be multi-sectoral.

Take the economic aspect. A recent World Bank study shows that raising taxes on tobacco brings down the consumption. A 10 per cent increase in prices could lead to an average of 7 percent decrease in demand in developing countries and a 4 percent fall in industrialised countries. It could also discourage the addiction to tobacco while providing an incentive to those who wish to quit the habit. It would benefit in particular the poor and the young people to whom smoking may appear fashionable.

The Mayor of New York City in a magazine article observed “In New York we have seen how effective anti-smoking campaigns can be. I signed a law prohibiting smoking in all work places. There was a huge outcry but then something happened. People loved it. Bars and restaurants saw their business increase.... Pretty soon cities and states around the country along with England, Ireland, France Italy and other countries with high rates of smoking began passing similar laws. Along with the smoking ban we raised cigarette taxes in New York, ran hard hitting public education campaigns... The result? After 10 years of seeing no decline in smoking we have cut rates in smoking by 21 percent and we have cut teen smoking by more than 50 percent. There are 300,000 fewer smokers in New York than there were six years ago.” This is an impressive achievement due to the initiative of Michael B. Bloomherd, Mayor of New York City. His considered opinion is that raising taxes on tobacco is “the most effective single way to reduce smoking, particularly among the young.” Interestingly the Mayor goes on to say “besides creating a disincentive, these taxes generate revenue needed to fund programs and advertising campaigns that help people to quit.

How does one see the picture in Sri Lanka? A recent newspaper article states the following - “Although Lankans smoked fewer cigarettes last year the sales volume of Ceylon Tobacco Company, the only cigarette manufacturer in the country, declined due to the affordability factors. The Company paid a massive Rs. 50 billion tax to Government, CTC said in a news release.” CTC had also increased its profit after tax by Rs. 867 million despite lower sales. The sales volume had dropped as a result of higher excise led price increase and diminishing consumer affordability of cigarettes. By paying Rs. 50 billion to the Treasury the CTC had paid Rs. 9 billion more than last year and was one of the largest contributors to Government revenue. The CTC appears to be proud of its “bold and innovative initiatives” which made significant savings possible.

Thus, our local experience appears to be in sharp contrast to that of the Mayor of New York. Our experience of gradual increases in tobacco prices through the budget appears to be an exercise in raising funds to bridge the budget deficit rather than a frontal attack by a sharp and dramatic increase of prices to reduce smoking from the health point of view. It will be interesting to compute the cost of the medical bill in treating smoke-related diseases as against the “income” to the Treasury by way of taxes. The total cost of medical attention is sure to far outweigh the benefit of the Rs. 50 billion by way of taxes.

Two aspects of relevance are, the reaction of the tobacco industry (generally) to the Campaign to reduce tobacco use initiative by the World Health Organization.

the reaction of the pharmaceutical industry.

The reaction of the tobacco industry is well encapsulated in the words of the Director General of the WHO who stated “The tobacco industry never gives up.” With every new successful control mechanism in one country, new approaches are constantly being devised. New forms of marketing emerge. As the DG says “As the Marlborough man has been removed from the billboards in the United States, he now rides high across Asia and the Middle East. Clothing, boots and adventure trips carry the Marlborough logo where previously the cowboy stood.”

This is not all. Court Cases in USA have brought to light over 35 million pages of documents that tell a story of deception. He says “The global scale and precision of the tobacco industry plan to subvert political process, to obstruct the United Nations including the WHO is, truly astonishing.”

Pharmaceutical Companies are no better. They are as profit driven as most multinationals are. The IAEA report for a National Cancer Control Programmes submitted to the Ministry of Health noted, in relation to drugs and cancer treatment that “pharmaceutical companies are pushing expensive drugs and doctors are forced to prescribe generic drugs. In India it would appear the “situation is critical” and that there is “no control of pharmaceutical companies.”

Despite these problems the way forward is not to given in to despondency though to loosen tobacco’s grip is not easy. Since a people’s health is a prime consideration - even a fundamental right in some States - it behoves the States to strike the right balance between a nations health, tobacco revenue and trade.

That taxes work is amply shown by the experience noted by New York’s Mayor. A sharp increase in taxes rather than a gradual increase will induce many more smokers to quit. Sustained advertising bans, prevention of sponsorships of sports and the activities of youth, controls on marketing (in Japan Western cigarettes brands are marketed as a kind of “liberation tool”, where companies are urging young women to assert themselves, shed their inhibitions and smoke), avoidance of targeting specific groups like Hispanic and Asian American & black communities, banning sale of cigarettes/beedies etc. to young people are some of the measures. It is found that 80 per cent of smokers start before they are 18 years of age. What do children know about “informed choice,” which is the classic defence of the tobacco industry, at that age. Tobacco-free work places and homes must be insisted on. The woman and particularly mothers should insist that their homes be smoke-free as children are more prone to respiratory illnesses such as bronchitis, pneumonia, asthma etc.

Passive smoking is equally deleterious to good health.

The way forward is for strong legislation to be effectively implemented. We have made an effort with the National Authority on Tobacco & Alcohol Act 27 of 2006. The functions inter alia are to advise the Government on the implementation of the National Policy on Tobacco and Alcohol to, recommend legal, taxation administration measures necessary to implement the National Policy on Tobacco & Alcohol.

If there is such a statement of National Policy it is not sufficiently well known. The offences under the Act are set out in part II of the Act but this legislation does not appear to have a marked effect.

The way forward is to follow the strategies adopted by the Mayor of New York who along with the WHO developed a strategy called MPOWER which has proved to be able to save lives.

Monitor tobacco use and preventive policies. It is essential to monitor how the strategies adopted affect smoking rates.

Protect people from second hand smoke. A smoke free environment is the only proved way to protect people.

Offer to help people to quit the habit. Warn about the dangers of tobacco Enforce the law on advertising, promotion, sponsorship etc.

Raise taxes on tobacco. That is the most effective single way to reduce smoking particularly among the young.

The Mayor says that no country has fully implemented all these policies. But people and officials are beginning to stand up to tobacco companies.

His exhortation is worth repetition “fighting tobacco is the single most effective way to prevent premature deaths. A billion lives hang in the balance.”

The writer is Chairman of the Education Committee of the Cancer Society.

With proper lung management:

Asthma treatable

by Rohana JAYALAL

Public awareness campaign was held by the Glaxosmithkline Pharmaceuticals to mark the World Asthma Day which fell on May 5 with the participation of Dr. Amitha Fernando (Consultant, Respiratory Physician at Central Chest Clinic Colombo) , Dr. Kirthi Gunasekera (Consultant Respiratory Physician) Dr. Eshant Perera (Consultantt Respiratory Physician of Kalutara Hospital.The event was held at the Park Premier Banquet Hall, Excel World,Colombo.

Asthma control is appallingly inadequate in most countries. It has been estimated that there are around 300 million asthmatics worldwide. Over the past decade asthma has increased by over 50% globally. Meanwhile it has been documented that 25% of children and 10% of adults suffer from asthma.

In Sri Lanka available data suggest that there are around two million asthmatics. At present it is the second most frequent cause of hospitalisation. Asthma causes much suffering in that disruption of day to day living in terms of an illness leads to loss of income of those employed and also hampers schooling and education of children.

If you suffer from asthma do not feel distressed. Over the past years much has been learnt of asthma. Very effective new medicine have become available and doctors are equipped with new strategies in combating this condition.

Asthma is the air breath carried into and out of lungs by a system of finely branched tubes.These tubes begin from the trachea (Windpipe) in our throat and are connected to the nose and upper air passages. The trachea as it travels in our chest cavity divides into two main branches(The right and left main bronchi)each of which divides repeatedly like branches of a tree until they reach the air exchanging surfaces of the right and left lungs.

These tubes consist of a wall lined by muscle and a hollow interior which allows the smooth passage of air.

The hollow interior is lined by tissues rich in blood vessels, nerve endings and mucous (Phlegm) glands.

It is essential that hollow interior is maintained without narrowing or obstruction of its inner surface for the smooth passage of air.

Asthma patients are sensitive to a variety of factors that causes their airways to react abnormally when exposed to these factors. The muscles around the outer wall squeeze these tubes tight, the inner lining becomes swollen and the glands on the inner lining produces large amounts of mucus (Phlegm). The end result is a narrowed tube that makes passage of air extremely difficult.

Asthma affects people of all ages, but it most often starts in childhood. In Sri Lanka available data suggests that there are around 2 million asthmatics. It is second most frequent cause of hospitalisation.

Young children who have frequent episodes of wheezing with respiratory infections, as well as certain other risk factors, are at the highest risk of developing asthma that continues beyond 6 years of age.

Asthma symptoms are coughing, wheezing or whistling noises in the chest, chest tightness and difficulty in breathing and limitation of physical activity. All people who have asthma have these symptoms, but having these symptoms doesn’t always mean that they have asthma. A lung function test, done along with a medical history and physical exam. Is the best way to diagnose asthma for certain. Asthma is a long-term disease that can’t be cured easily. The goal of asthma treatment is to control disease,prevent chronic and troublesome symptoms such as coughing and shortness of breath reduce patient need of quick relief medicines. It helps you maintain good lung function, so let patient maintain his/her normal activity levels and sleep through night prevent asthma attacks that could result in patients going to the hospital for treatment. Parents and patients should actively co-operate with the doctor to manage your asthma or child asthma.

Asthma is treated with two types of medicines. They are long-term control and quick relief medicines. Long-term control of medicines help reduce airway inflammation and prevent asthma symptoms. Quick relief medicines relieve asthma symptoms that may flare up.

Level of asthma control can vary over time and with changes in patient’s home, school or work environments. According to the test, doctor may need to increase medicine. If asthma doesn’t stay under control.

If you follow an asthma action plan you can work with doctor easily. If children have asthma, all of people who care for him/her should know about the children asthma action plan.Care takers can help children follow his/her action plan.

Avoid things that can worsen asthma. A number of common things can set off or worsen asthma symptoms. Once you know what factors are you can take step to any of them. If exposure to pollens or air pollution makes asthma worse, try to limit time outdoors when the levels of these substance are high in the outdoor air. If you have asthma go to the doctor and follow his/her advice. Then you will control your or children’s asthma well.