Smoking Cessation in Malaysia by MR CHANDRAN KANNIAH AMP HEALTH EDUCATION OFFICER HOSPITAL IPOH

1. Smoking Cessation in Malaysia byMR CHANDRAN KANNIAH AMPHEALTH EDUCATION OFFICER HOSPITAL IPOH CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

2. 5 principal causes of all medically certified deaths(Govt. Hosp.1998) 1. Heart diseases & diseases of pulmonary circulation 14.09% 2. Septicaemia 12.54% 3. External causes 9.67% 4. Cerebrovascular diseases 9.36% 5. Malignant Neoplasm 8.91% CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

3. Smoking Statistics (NHMS) 1986 1996 Overall 21.5% 24.8% Male 40.9% 49.2% Female 4.1% 3.5% Urban 19.2% 21.7% Rural 22.7% 28.6% Malay 23.7% 27.9% Chinese 17.7% 19.2% Indian 15.2% 16.2% Others 32.8% 32.4% CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

4. Youth smoking statistics • People age 18 years and < • Prevalence 1996 - 16.9% (male : 30.7%, female : 4.8%) 1999 - 18.2% (males : 29%, females : 8%) Daily, 45 - 50 youths start to take up smoking CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

5. Number of smokers – Estimates 2000 2025 Population 22 m 30 m Population ( < 15 years) 7.5m (34%) 7.2m (24%) Population ( > 15 years) 14.5m (66%) 22.8m (76%) Prev. adult smokers : Male smokers 49% 30% Female smokers 4% 10% Overall adult prev. 25% 20% Number of adult smokers 3.6 m 4.6 m CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

6. Risks Death from: Relative Risk Lung cancer 20 X (90% of all lung cancer) Vascular disease - IHD, strokes, others 3 X (25% of all CHD) Chronic lung disease (75% of all COAD) Tobacco is now killing 4 million people worldwide (1:10 adult deaths) If current trend persist, ~ 500 million people alive today will eventually be killed by tobacco, half of them in productive middle age, losing 20 – 25 years of life ~ 70% of smokers have made at least 1 prior quit attempt & ~ 40% try to quit each year CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

7. Will Quit Smoking Modify One’s Risks? Duration of Quit Benefits 20 minutes BP, PR, T° return to normal 8 hours CO level in blood return to normal 24 hours immediate risk of heart attack starts to fall 48 hours nerve ending starts to regrow 14 days circulation improves, lung fn increase 30% 1 month most nicotine withdrawal symp. Disappear 3 months lung fn improve, nagging cough disappear, cilia regrow in the lungs 9 months risk in pregnancy cx reduced 1 year excess risk of CHD halfed 5 years risk of lung ca halfed, stroke risk = non-smoker, risk of mouth, throat & oesoph.ca halfed 10 years lung cancer death rate = non-smoker, pre-cancerous cells replaced 15 years risk of CHD= non-smoker CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

8. Risks Relative risks (RR) – represents the likelihood of disease in the exposed individual relative to those who are not exposed RR = Ie / Io Risk difference (RD) or Attributable risk (AR) – is the absolute effect of exposure or the excess risk of disease in those exposed compared with those non exposed AR = Ie - Io Population Attributable Risk (PAR) – excess rate of disease in the total study population of exposed and non exposed individuals that is attributable to the exposure PAR = (AR) (Pe) Pe = Proportion of exposed individual in the population CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

9. Is Tobacco Control Worth Paying For? Cost-effectiveness of any health intervention can be evaluated by estimating the expected gains in years of healthy life that each will achieve in return for the requisite public costs needed to implement that intervention. 1993 WORLD DEVELOPMENT REPORT - “Investing in Health” Tobacco control policies are considered cost-effective and worthy of inclusion in a minimal package of healthcare. Policy based programmes cost about US$ 20 – 80 per discounted year of healthy life saved (1 disability-adjusted life year – DALY) CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

10. National Tobacco Control Programme • Legislation - Control of Tobacco Products Regulations 1993 • Health Promotion • CERAH – Youth Programme • Price measures – Taxation • Smoking Cessation • Smoke-free policy • Tobacco Advertising Ban & Counter Advertising • Research • Litigation • Trade & agricultural aspects CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

11. International Action FRAMEWORK CONVENTION ON TOBACCO CONTROL (FCTC) • An international legal instrument aimed to circumscribe the global spread of tobacco and tobacco products under the WHO • First time WHO has activated Article 19 of its constitution • FCTC negotiations and the adoption of the Convention is a process and a product in service of public health. • Legally binding treaty to signatories • WHA 1999 foresees the adoption of the FCTC and possible related protocols by WHO no later than May 2003 CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

12. Will Smoking Cessation Programme Make An Impact? 1999 WORLD BANK REPORT – “Curbing the Epidemics” Unless current smokers quit, tobacco deaths will rise dramatically in the next 50 years. Therefore, governments concerned with health gains in the medium term should wish to encourage adults to quit. For low / Middle Income Countries Price increase of 10% US$ 4 – 17 per DALY saved Non-price measures with Effectiveness of 5% US$ 68 – 272 per DALY saved NRT (publicly provided) with 25% Coverage US$ 276 – 297 per DALY saved (1 DALY + 1 lost year of healthy life) CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

13. National Smoking Cessation Programme General Objectives  Provide comprehensive support and assistance to help smokers quit smoking Specific Objectives: 1. Develop skills of assisting smokers to quit among all health professionals 2. Make quit smoking services widely available and accessible at all levels of health care 3. Encourage and motivate smokers utilise the services provided. 4. Involve all stakeholders in partnership to help smokers quit CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

14. National Smoking Cessation Programme STRATEGIES 1. Improve capacity building in area of expertise and infrastructure that will facilitate the establishment of comprehensive and effective quit smoking programme 2. Promote and advertise the availability of quit smoking services to the public and specific groups 3. Make all available all evidence-based treatment modalities 4. Inform and educate smokers about the benefits of quitting smoking CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

15. National Smoking Cessation Programme STRATEGIES 5. Promote community outreach quit smoking programmes 6. Integrating quit smoking programme (QSP) into all relevant health programmes. 7. Establish QSP Task Force at national, state and district levels. 8. Networking and collaborative with other agencies nationally and globally 9. Establish smokers anonymous groups CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

16. Problems Related To Smoking Cessation Clinicians are reluctant to address the smoking problem because: • it is believed that tobacco dependence is a habit and not a dependent disorder(chronic relapsing illness) • lacks adequate knowledge and skills to treat tobacco use and dependence • most do not realise that brief intervention can increase the quit rate among smokers. • most thought that pharmacotherapy is only to be used in intensive cessation treatment. CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

17. National Smoking Cessation Programme • Quit Smoking Manual – Dedicated Quit Clinics • Training Module • Clinical Practice Guideline – All health care providers (doctors, dentists, pharmacists, paramedics & allied health – in an integrated scheme of service provision at the private or public sector) CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

18. Clinical Practice Guideline • Assessment of tobacco Use • Clinical interventions • Brief Clinical Intervention • Intensive Clinical Intervention • Pharmacotherapy • Special Population CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

19. Assessment of Tobacco Use • All patients should be asked if they use tobacco and should have their tobacco-use status documented on a regular basis. • Evidence has shown that this significantly increases rates of clinician intervention • Guideline in assessing tobacco use. CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

20. Brief Clinical Intervention • This intervention only requires 3 minutes of the clinician time • It has 3 types of intervention addressing • Smokers who are willing to quit • Smokers who are unwilling to quit • Smokers who have recently quit. • A guideline is provided using 5A’s (ask, advise, assess, assist, arrange) and 5R’s (relevance, risks, rewards, roadblocks, repetition) CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

21. Intensive Clinical Intervention • Evidence shows that more intensive tobacco dependence treatment is more effective than brief treatment. • This could be achieved by increasing • the length of individual treatment sessions • the number of treatment sessions • specialized behavioural therapies. CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

22. Dedicated Quit Smoking Clinics • Counseling (smoking, diet, stress) • Individual / Group • Pharmacotherapy • Motivation (dental care, CO analyser, lung function, blood analyses) • Referrals • Close monitoring & F/U CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

23. Pharmacotherapy • In addition to counseling, all smokers should receive pharmacotherapy if they fulfill the criteria below: • with scores from Fagerstrom’s questionnaire of > 4 • smoking > 10 cigarettes per day CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

24. Pharmacotherapy • Recommended first line agents includes: • Nicotine replacement therapies (NRT, e.g., gum, patch, nasal spray and inhaler) • Sustained release (SR) bupropion • Recommendedsecond line agents includes: • Clonidine • Nortriptylline • Combination of pharmacotherapies has been shown to be more efficacious than a single agent: • 2 NRT’s • Bupropion and a NRT CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

25. Special Population • Gender: women. • Pregnancy • Hospitalized smokers • Psychiatric population. • Children and adolescents. • Elderly. CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL

26. THANK YOU CHANDRAN KANNIAH AMP HEO IPOH HOSPITAL