2. SMOKING CESSATION (Treating Tobacco Use and Dependence) Public Health Department Faculty of Medicine UNPAD

3. DR. Ardini Saptaningsih RAKSANAGARA dr.,MPH Date of Birth: 21 Mei 1960 Address : Jalan Pasang 26, Bandung-40114. Education 1986, Dokter : Fakultas Kedokteran, Unpad. 1992, Master of Public Health (MPH): University of Wollongong, Wollongong, Australia. 2004, Doktor : Pascasarjana, Unpad Work Experience 1987 - now : Lecture Public Health Department Faculty of Medicine Unpad 2007 - 2010 : Director Public Health Postgraduate Program Faculty of Medicine Unpad 2010 - 2011 : Head Department of Public Health Faculty of Medicine Unpad Ardini Saptaningsih RAKSANAGARA Jalan Pasang 26. Bandung 40114. Phone : 022-7276326 Mobile phone : 0811 237 159 Email : araksanagara@yahoo.comaraksanagara@yahoo.com

4. WHY IS TOBACCO A PUBLIC HEALTH PRIORITY ? Tobacco  Public Health Problem ! Tobacco is the second major cause of death in the world.

5. It is currently responsible for the death of one in ten adults worldwide (about 5 million deaths each year) Tobacco is the fourth most common risk factor for disease worldwide

6. If current smoking patterns continue,  it will cause some 10 million deaths each year by 2025. Half the people that smoke today – that is about 650 million people – will eventually be killed by tobacco.

7. WHY IS TOBACCO A PUBLIC HEALTH PRIORITY? The economic costs of tobacco use are equally devastating. – high public health costs of treating – tobacco-caused diseases, – tobacco kills people at the height of their productivity, depriving families of breadwinners and nations of a healthy workforce. – Tobacco users are also less productive while they are alive due to increased sickness.

9. WHY IS TOBACCO A PUBLIC HEALTH PRIORITY? Tobacco and poverty are inextricably linked. – Many studies have shown that in the poorest households in some low-income countries as much as 10% of total household expenditure is on tobacco. – This means that these families have less money to spend on basic items such as food, education and health care. In addition to its direct health effects, tobacco leads to malnutrition, increased health care costs and premature death. – It also contributes to a higher illiteracy rate, since money that could have been used for education is spent on tobacco instead.

13. Every day, there will be patients come to your practice to consult about their symptoms/ diseases. Still, even though they will not complain about their smoking habits, you as a good doctor has to screen them for tobacco dependence as a routine procedure

16. WILLINGNESS TO QUIT

20. Unwilling to quit 5 R’S – Relevance – Risks – Rewards – Roadblocks – Repetition

21. UNWILLING TO QUIT

24. Percentage of smokers (groups of age)

25. Everyday smokers Male : 45 % Female : 3 % Urban : 21.2 % Rural : 25.3 %

26. Household expenditure

27. 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 %

28. Why tobacco ? 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

29. Why tobacco control? Illnesses caused by tobacco are completely preventable

31. Why progress difficult? Tobacco industry Economic self-interest :  to get as many people to smoke as many cigarettes as possible

32. Reducing tobacco use Educational Clinical Regulatory Economic Social or comprehensive

33. Educational School based curriculum – Conducted in conjunction with community and media –based activity Mass media or counter-advertising program Media campaign  change social norms around tobacco used – Decrease adolescent initiation – Increase adults cessation

34. Clinical Pharmacologic Behavioral Regulatory Product manufacture – Filter, low tar – Promotion, marketing Sale Smoking restriction – Public venues – worksites

35. Economic Modify taxation Tariffs Trade policy Comprehensive approach Reduce demand and supply

36. Smoking 400,000 Accidents 94,000 2 nd Hand Smoke 38,000 Alcohol 45,000 HIV/AIDS 32,600 Suicide 31,000 Homicide 21,000 Drugs 14,200 Consequences of Tobacco-Use: Preventable Causes of Death

37. What are the tobacco-related diseases that are contributing to all these deaths?

38. Tobacco use: The single largest cause of preventable death.

39. Arteriosclerosis & Atherosclerosis: Healthy arteryDamaged artery

40. Heart Attack: Quitting smoking rapidly reduces the risk of coronary heart disease Torn heart wall: R esult of over-worked heart muscle Smokers are twice as likely as Nonsmokers to have a heart attack

41. Peripheral Vascular Disease

42. Stroke: This brain shows stroke damage, which can cause death or severe mental or physical disability

43. Emphysema: Healthy lung Emphysematic lung Symptoms Include  Shortness of breath  Chronic cough  Wheezing  Anxiety  Weight loss  Ankle, feet and leg swelling  fatigue

44. Lung Cancer: The uncontrolled growth of abnormal cells in one or both lungs Lung cancer kills more people than any other type of cancer

45. Fetal Damage: Fetal Smoking Syndrome: Birth defects Premature stillbirth Low birthweight Prone to Sudden Infant Death Syndrome Lowered immune capacity

46. Laryngeal Cancer Symptoms: Persistent hoarseness Chronic sore throat Painful swallowing Pain in the ear Lump in the neck Over 80% of deaths from laryngeal cancer are linked to smoking

47. Dental Problems: Above : Cavities Below: Gingivitis Overall poor oral health Common Consequences: Stained teeth Gum inflammation Black hairy tongue Oral cancer Delayed healing of the gums

48. Consequences of chewing tobacco: Leukoplakia Oral cancer

49. Chemical Box: What’s in Tobacco?  Tar: black sticky substance used to pave roads  Nicotine: Insecticide  Carbon Monoxide: Car exhaust  Acetone: Finger nail polish remover  Ammonia: Toilet Cleaner  Cadmium: used batteries  Ethanol: Alcohol  Arsenic: Rat poison  Butane: Lighter Fluid

50. If smoking is so bad for us, why do we start?

51. Tobacco Myths Myth: Clove cigarettes are less harmful than regular cigarettes. Myth: Cigars are safe Myth: It’s OK to smoke as long as it’s a “natural” cigarette Conclusion: All tobacco products are addictive (which takes your independence away), cause cancer, and harm non-smokers all around you. The average tobacco user is addicted for seven years before they can finally kick this enslaving habit!

52. What is a cigar?  A cigar has larger amounts of tobacco than a cigarette  A cigar is tobacco rolled up in a tobacco leaf  A cigar does not have a filter

53. Cigar Use: Using beauty and fame to promote a dirty, devastating habit

54. Hookahs: Not safer than regular tobacco smoke. Causes the same diseases Raises the risk of lip cancer, spreading infections like tuberculosis. Users ingest about 100 times more lead from hookah smoke than from a cigarette.

55. The Quit Plan: Treat yourself well Drink lots of water Change your routines Reduce stress Deep breathing Regular exercise Do something enjoyable every day Increase non-smoking social support Other ideas?

56. Get Medication and Use It Correctly Talk to your health care provider about which medication will work for you: Available by prescription: Zyban (Wellbutrin, Bupropion) Nicotine Inhaler Nicotine Nasal Spray Available over-the-counter: Nicotine Patch (Has an increase in efficacy when combined with Zyban) Nicotine Gum and lozenge

57. Conclusion All patients should be asked if they use tobacco and should have their tobacco-use status documented on a regular basis. Once a tobacco user is identified and advised to quit, the clinician should assess the patient’s willingness to quit at this time. All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates.

58. Proactive telephone counseling, group counseling, and individual counseling formats are effective and should be used in smoking cessation interventions. All patients who receive a tobacco dependence intervention should be assessed for abstinence at the completion of treatment and during subsequent clinic contacts.

59. Three types of counseling and behavioral therapies result in higher abstinence rates : (1) providing smokers with practical counseling (problem solving skills/skills training); (2) providing social support as part of treatment; and (3) helping smokers obtain social support outside of treatment. These types of counseling and behavioral therapy should be included in smoking cessation interventions.