Chapter 1- Tobacco Epidemic And Disease Burden

Chapter I Tobacco Epidemic and Disease Burden Introduction Non-communicable diseases (NCD) or lifestyle diseases, such as cancers, stroke, heart diseases, diabetes and chronic obstructive pulmonary disease, represent a significant burden on public health and are likely to account for an increasing share of diseases in the future, particularly in developing countries. Globally, 60% of deaths are currently due to these diseases, amounting to more than 40 million deaths annually in both developing and developed countries. 1

Projected trends show that

by 2020, NCDs are expected to account for 73% of global deaths and 60% of the disease burden. A number of risk factors are associated with NCDs and each year at least:

2

•

4.9 million people die due to tobacco use;

•

1.9 million people die due to physical inactivity;

•

2.7 million people die due to low fruit and vegetable consumption;

•

2.6 million people die due to being overweight or obese;

•

7.1 million people die due to raised blood pressure; and

•

4.4

million

people

die

due

to

raised

total

cholesterol levels. This disturbing picture is associated with changing socioeconomic, cultural, political and environmental climate. Globalization and urbanization serve as channels for the promotion of unhealthy habits and behaviors (e.g. tobacco and alcohol use, unhealthy diets, and physical inactivity) and environmental changes (e.g. indoor and outdoor air pollution).3

Such risky habits and environments lead to major non-

communicable diseases. Promoting a healthy lifestyle within countries, communities and families by addressing risk factors such as tobacco use, alcohol use, unhealthy diets and physical inactivity is essential to decrease the persistent increase of non-communicable diseases. A healthy lifestyle is a way of living that lowers the risk of being seriously ill or dying early. Not all diseases are preventable, but a large proportion of deaths, particularly those from coronary heart disease and lung cancer, can be avoided.4 And

1

one of the primary interventions to cut back on this growing problem is to promote tobacco control nationally and globally. Prompt action is crucial.

The tobacco epidemic already kills

5.4 million people a year from lung cancer, heart disease and other illnesses.

If unchecked, that number will increase to

more than 8 million a year by 2030. – Dr. Margaret Chan, Director General, World Health Organization To provide a general appreciation of the health effects of smoking and tobacco use at the global, regional (Western Pacific Region) and the Philippines and the frameworks to address non communicable diseases, the following topics will be discussed: •

Prevalence of Smoking and Tobacco Use:

Global, Regional and Philippine

Facts and Figures •

Burden of disease and Tobacco Related diseases – Health Impact

Integrated Non-Communicable Disease Prevention and Control Frameworks

Learning Objectives: At the end of the chapter, the trainees should be able to:

1.

Describe the global tobacco epidemic;

2.

Describe the health effects of tobacco use; and

3.

Discuss the problems associated with tobacco use as shown by

evidence.

I.

Prevalence of Smoking and Tobacco Use: Global, Regional and Philippine Facts and Figures Tobacco use is one of the biggest threats to public health and is the

single most preventable cause of death throughout the globe. It is a risk factor for six of the eight leading causes of deaths in the world.5 According to the Oxford Medical Companion (1994) “tobacco is the only legally available consumer product which kills people when it is entirely used as intended”.

6

Globally, tobacco

2

use kills 5.4 million people a year—an average of one person every six seconds. This accounts for one in 10 adult deaths worldwide.7 In the 20th century, 100 million deaths were caused by tobacco and most were from the Western countries and former socialist countries.

By

2000, it was found that majority of the smokers from 15 years and older were in South East Asia and in the Pacific – 38% (Fig. 1). If this remains unchecked, tobacco-related deaths will increase to more than eight million a year by 2030, and 80% of those deaths will occur in the developing world. In the 21st century, there will be up to one billion deaths8 and many will be from low income countries. Further, 250 million teenagers and children in the world will be killed by tobacco use unless smoking trends change dramatically.9 Fig. 1 Distribution of Smokers by Region, Aged 15 and Older, 2000

Highincomeeconomies 18%

38%

MiddleEast andNorth Africa 3% 6% 9%

SubSaharanAfrica LatinAmericaandthe Carribean EuropeandCentral Asia SouthAsia

15%

11% East AsiaandthePacific

Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 46.1

A.

Adult Smoking and Tobacco Use

According to the research on adult smoking done by Jha et. al in 2002, there were 1.1 billion smokers all over the world, 82% are found in low-income countries. 10 As shown below, there are more males smokers than females. More smokers are found in low and middle-income countries (920 million); however the percentage of male and female smokers in high income countries (37% and 21%) are closer than in low income countries (49% and 8%). The Western Pacific region, which covers the East Asia and the Pacific, has the highest smoking prevalence among males at 63% and has the most number of smokers compared to the rest of the regions. Based on the table below, overall adult smoking prevalence in the Western Pacific Region comprises 34.7% or about 35 persons smoke out of a 100.

3

Table 1 Estimated Prevalence of Smoking by Region, Gender and Number of Smokers, 15 years and above, 200011

World Bank region

Smoking Prevalence (%) Female Males Overal s

Total Smokers Million % of all

East Asia and the Pacific Europe and Central Asia Latin America and the

63 56 40

5 17 24

l 34 35 32

s 429 122 98

smokers 38 11 9

Caribbean Middle East and North Africa South Asia Sub-Saharan Africa Low and middle-income

36 32 29 49

5 6 8 8

21 20 18 29

37 178 56 920

3 15 6 82

economies High-income economies

37

21

29

202

18

Source: Disease Priorities in Developing Countries: Tobacco Addiction, Chapter 46, p. 871

In the Philippines, the increase in deaths associated with NCD remains unabated since 1990s. This is partly due to the growth in the prevalence of smoking in the country. Based on World Health Survey figures in 2003, the Philippines’ adult current tobacco smoking prevalence was pegged at 57.5% and 12.3%, for males and females respectively. B. Youth Smoking and Tobacco Use On youth smoking prevalence, the Global Youth Tobacco Surveillance (GYTS) has been at the forefront in analyzing trends in youth smoking around the world.

Since 1999, the GYTS has been implemented in 140 countries and 11

territories and across all six World Health Organization (WHO) regions. These regions are the African Region (AFR), Region of the Americas (AMR), East Mediterranean Region (EMR), European Region (EUR), South-east Asian Region (SEAR) and the Western Pacific Region (WPR). This survey is repeated in these areas every 4 to 5 years. GYTS is a school-based survey of a defined geographic site identified as a country, a province, a city, or any other geographic entity.

The survey contains

questions on tobacco use, knowledge and attitudes regarding tobacco, secondhand smoke (SHS) exposure, pro- and anti-tobacco media and advertising exposure, desire

4

for cessation, access and availability to obtain tobacco products, and knowledge on the harmful effects of tobacco use as taught in school.12

The Global Tobacco

Surveillance System (GTSS) houses the GYTS together with the other surveys: Global School Personnel Survey, the Global Health Professions Student Survey, and the Global Adult Tobacco Survey. According to the analysis of the GYTS conducted from 2000 to 2007 by the Centers fir Disease Control and Prevention (CDC) and the WHO, the overall prevalence of students who currently smoked cigarettes is 9% or 9 out of 100 students. Further, “Approximately 15% of students smoked cigarettes in four of the 29 sites in AFR, 13 of the 38 sites in AMR, one of the 23 sites in EMR, 15 of the 29 sites in EUR, one of the 10 sites in SEAR, and 13 of the 22 sites in WPR... Boys were significantly more likely than girls to smoke cigarettes in AFR, EMR, SEAR, and WPR; no significant differences were observed by sex in AMR and EUR. Of the 151 sites, no sex differences were observed in 87 sites, boys were significantly more likely than girls to smoke cigarettes in 59 sites, and girls were significantly more likely than boys to smoke in 5 sites”.

– Global Youth Tobacco

Surveillance 2000-2007, CDC, 2008 Other key findings of the study include the following:

•

One in 10 (10.1%) students currently used tobacco products other than cigarettes (e.g., pipes, water pipes, smokeless tobacco, and bidis), with the rate highest in EMR (12.0%) and lowest in WPR (6.6%);

•

Among students who had never smoked cigarettes, 19.1% indicated they were susceptible to initiate smoking during the next year. The rate was highest in EUR (29.8%) and lowest in WPR (13.4%);

•

Cigarette smoking was significantly higher than other tobacco use in AMR, EUR, and WPR; other tobacco use was significantly higher than cigarette smoking in EMR and SEAR;

•

Overall, approximately four in 10 students (42.5%) were exposed to smoke in their home during the week preceding the survey. Among the six regions, exposure to second hand smoke (SHS) at home was highest in EUR (77.8%) and lowest in AFR (27.6%). In

5

the other four regions, exposure to SHS at home ranged from 50.6% (WPR) to 34.3% (SEAR);

•

Approximately half (55.1%) of all students were exposed to second hand smoke (SHS) in public places during the week preceding the survey. Exposure to SHS in public places was highest in EUR (86.1%);

•

More than three fourths (78.3%) of students in all regions thought smoking should be banned in all public places;

•

Overall, one in 10 students (10.0%) had been offered free cigarettes by a tobacco company representative. The rate was highest in AFR (12.2%) and lowest in WPR (8.0%);

•

Overall, 68.7% of students who currently smoke cigarettes reported that they desired to stop smoking. The desire to stop smoking was highest in WPR (80.7%) and lowest in AMR (53.3%);

•

Overall, five in 10 (46.7%) students who currently smoke cigarettes usually purchased their cigarettes in stores. The rate was highest in EUR (61.7%) and lowest in AMR (20.2%);

•

Seven in 10 (70.5%) students who bought cigarettes in a store were not refused purchase of cigarettes during the month preceding the survey because of their age. The rate was lowest in WPR (47.9%) and approximately 70% in EUR, EMR, and AMR; and

•

Overall, more than half of the students (57.6%) reported having been taught in school about the dangers of tobacco during the preceding school year. The rate was highest in WPR (68.8%) and lowest in EMR (47.5%).

The survey findings yielded a recommendation to implement effective interventions that can decrease tobacco use among the youth.

Such may

include increasing excise taxes on tobacco products, media campaigns, school

programs

in

conjunction

with

community

interventions,

community interventions that decrease minors' access to tobacco.

and

It also

suggested that interventions should be broad-based but focused on boys and girls and must have strategies directed at smoking/tobacco use prevention and cessation.

This is to decrease the morbidities and mortalities

attributed to tobacco use in the future. Some specific figures on the Western Pacific region based on the GYTS showed that 13.4% of boys and girls 13-15 years of age currently smoked. Of which 18.5% are boys and 8.4% are girls. 6.6% of those surveyed in the region currently

6

used tobacco products aside from cigarettes and 13.4% represent those who never smoked and are susceptible to products other than cigarettes.

Table 2 Prevalence of Current Tobacco Use and Smoking among Youth, 2004 and 2007, Philippines Year 2004 2007

Youth Prevalence of Current Tobacco Use (%)* Males

Females

Both

21.4 23.4

11.8 11.8

15.9 17.3

Source: MPOWER, 2008; *Global Youth Tobacco Survey 2004;

In the Philippines, the table shows an increase in youth prevalence from 2004 to 2007. Of the 3, 278 boys and girls 13-15 years of age surveyed through GYTS in 2007, 17.3% currently smoked. Of which 23.4% are boys and 11.8% are girls. 7.7% currently used tobacco products other than cigarettes and 12.8% were the never smokers susceptible to products other than cigarettes.

II.

Burden of Disease and Tobacco-Related Diseases – Health Impact Unlike other dangerous substances, for which the health impacts may be immediate, tobacco-related diseases usually do not begin for years or decades after tobacco use starts.

Because there is a lag of several years

between when people start using tobacco and when their health suffers, the epidemic of disease and death has just begun.

13

The figure below shows the proportion of

leading diseases attributable to tobacco use. These diseases include ischemic heart disease, cerebrovascular disease (stroke), lower respiratory infections, chronic obstructive pulmonary disease (COPD), tuberculosis (TB) and tracheal, bronchial and lung cancers.

As shown below, tobacco poses as a major and common risk

factor for these diseases or for the eight leading causes of death in the world! Fig. 2 Tobacco

Source: WHO Report on the Global Tobacco Epidemic – MPOWER Package, 2008, p.97

Use is a Risk Factor for Six of the Eight Leading Causes of Death in the World, 2005

Disability Adjusted Life Years (DALYs) is used by the WHO to measure the disease burden. One DALY is equal to a year of “healthy life” lost due to a disease. The sum of DALYs across populations (disease burden) is the measurement of the gap created between the current health status and the ideal situation where populations grow old/ advance in age without disease or disability. Table 3 shows that in 2000, DALYs lost due to tobacco use across populations is greatest in the East Asia and the Pacific Region (17,244), followed by Europe and Central Asia (15,093) and Latin America and the Caribbean (4,402). Table 3 Global Tobacco Deaths and DALYs Lost by Gender and Region, 2000 (in thousands)

World Bank Region

Tobacco Deaths

DALYs Lost

Men

Women

Men

Women

East Asia and the Pacific Europe and Central Asia Latin America and the

829 754

274 161

13,116 12,407

4,128 2,686

Caribbean

177

97

2,789

1,613

Middle East and North Africa South Asia Sub-Saharan Africa

97 768 105

28 187 66

1,676 12,397 1,659

554 3,285 1,091

Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 46.2

Further, smoking has been portrayed by the tobacco industry and its retailers as a manly or sexy habit and something that would bring about happiness, power, success and fitness. However, in life circumstances, it only leads to sickness, premature death and sexual dysfunctions.

Smoking slowly destroys almost every

organ in the body thereby causing many diseases. Smoking harms every part of the body and health effects come in the form of chronic diseases that deplete the overall health of the smoker. These non-communicable or lifestyle diseases include ischemic heart disease, cerebrovascular disease (stroke), lower respiratory infections, chronic obstructive pulmonary disease (COPD) and tracheal, bronchial and lung cancers. Below are graphic manifestations of the effect of ONE RISK FACTOR - tobacco use – on health.14

8

Throat Cancer

Breast Cancer

Chronic Obstructive Pulmonary Disease (CPOD)

9

Premature birth NCDs are likewise prevalent in the Western Pacific Region where 26% of the world’s population resides. In this region over 75% of deaths are attributable to non-communicable

diseases, compared to 14% of deaths caused by

communicable diseases. Cardiovascular disease and malignant cancers cause more deaths in middle- and low-income countries and areas within the Western Pacific Region than all communicable diseases combined 15 In the Philippines, heart diseases, cancers, vascular diseases, diabetes and COPD are 5 of the 10 leading causes of death. Three of these diseases are in the top 5 positions (diseases of the heart and the vascular system, cancers). These NCDs make up 40% of all Filipino deaths. Morbidity trends in 2003, on the other hand, showed that hypertension and heart diseases are leading causes of illness.

Fig.3

shows the unabated increase of NCD mortalities in spite of preventive, promotive and curative interventions implemented by the DOH, health facilities, health professionals and various organizations! Fig. 3 Mortality Trends of Selected Non-communicable Diseases, 1990-2003, Philippines.

90 80 70 60 Diseases of the heart

50 40 30

Diseases of the vascular system

20

Malignant neoplasm

10 2003

2000

1998

1997

1996

1995

1994

1993

1992

1991

1990

0

Source: DOH, 1990-2003.

10

Apart from the health effects of tobacco use, non-communicable diseases or lifestyle diseases represent a significant burden on public health regardless of the country’s economic development.

They are likely to account

for an increasing share of diseases in the future, particularly in developing countries. According to the WHO report entitled “Preventing Chronic Diseases:

A Vital

Investment”, countries can incur national income losses as a result of the impact of deaths from NCDs on the supply of labor and savings.

The

following data shows the estimated loss due to NCDs in 2005 for China was 18.3 billion, 11.0 billion for the Russian Federation and 9 Billion for India. According to the report, these losses accrue over time because each year more people die. Estimates for 2015 for the same countries are between approximately three and six times those of 2005. The cumulative and average losses are higher in the larger countries like China, India and the Russian Federation, and are as high as 558 billion international dollars in China.16

Table 4 Projected forgone national income due to heart disease, stroke and diabetes,

selected

countries,

2005-2015

(billions

of

constant

1998

UK

Tanzania

18.3

8.7

0.4

1.2

11.1

1.6

0.1

54.0

1.5

6.7

66.4

6.4

0.5

Russian

1.6

Pakistan

9.3

Nigeria

0.5

India

Canada

2.7

China

Brazil

International Dollars)

Internation Federation

al $

Estimated Income Loss in 2005 Estimated Income Loss in 2015 Accumulate d loss in 2005 value

49. 2

8.5

131. 8

557.

236.

7

6

7.6

30. 7

303.2

32. 8

2.5

Source: Preventing Chronic Diseases: A Vital Investment, p. 78

11

Integrated Non-Communicable Disease Prevention and Control Frameworks The World Health Organization

highlighted the need for the integrated

approach in the prevention and control of NCDs in the mid 1980s. During the 53rd World Health Assembly in 2000, the Global Strategy for the Prevention and Control of NCDs (WHA53.14) was adopted. The goal was to support Member States in their efforts to reduce the toll of morbidity, disability and premature mortality related to NCDs.

The plan of action entitled “Prevention and control of non-

communicable diseases: implementation of the global strategy” for 2008-2013 was recently endorsed by WHO Member States during the 61st World Health Assembly (2008).

Over the years other plans were developed to support NCD prevention and control. These include the following:

•

Regional Plan for Integrated Prevention and Control of Cardiovascular; Diseases and Diabetes for the Western Pacific Region 1998-2003;

•

Tobacco Free Initiative Regional Action Plan 2005-2009;

•

Plan of Action 2006-2010 for the Western Pacific Declaration on Diabetes; and

•

Regional Strategy to Reduce Alcohol-related Harm.

The most recent WHO initiated development in tobacco control is the MPOWER package.

Based on the WHO Report on the Global Tobacco Epidemic 2008,

countries must act NOW to reverse the epidemic and save millions of lives. The package presents new sources to help countries stop the disease, death and economic damage caused by tobacco use.

When implemented and enforced as a

package, six policies will prevent young people from starting to smoke, help current smokers quit, protect non-smokers from exposure to second hand smoke and free countries and their people from tobacco’s harm.17 In the country, the Integrated NCD Prevention and Control Program (INCDPCP) of the Department of Health commenced with the formulation of the Framework for the Integrated Community-Based NCDPCP in 2000. This was followed by the demonstration projects in Guimaras, Iloilo and Pateros, Taguig. Since then, the Program has gone a long way in promoting the integrated approach.

12

The vision of the INCDPC Program is to improve the quality of life of all Filipinos.

Its objectives are to reduce the exposure of population to risks

related to NCDs such as smoking, unhealthy diet, physical inactivity and to increase the proportion of NCD cases given appropriate treatment and care. The adoption of the integrated and comprehensive approach:

•

Focuses on common risk factors cutting across specific diseases guided by a life course perspective;

•

Encompasses the three levels of disease prevention: primary, secondary and tertiary level

•

Emphasizes strategies which would benefit the entire population or large sections of the population

•

Integrates across settings such as health centers, schools, workplaces and communities

•

Makes

explicit

links

to

other

government

programs,

community

based

organizations; and

•

Emphasizes inter-sectoral action.

INCDPCP Milestones 2000  The Training Module for Health Service Providers on the Integrated NCDPCP developed  The Degenerative Disease Office consisting of two divisions was mandated to manage the NCDPCPs under the National Center for Disease Prevention and Control;  The Health Sector Reform Agenda was introduced advocating changes of service delivery, governance, financing and regulations, which facilitated the integration of NCDPC-related efforts 2001  Demonstration Project: Integrated Community-Based NCDPC in Pateros and Guimaras. 2002  The Healthy Lifestyle approach: recognition of 3 major risk factors: physical inactivity, tobacco use and unhealthy diet  Philippine Heart Association staged a comprehensive advocacy program on the prevention and control of cardiovascular and other chronic diseases 2003  Launching of the “Mag HL Tayo Campaign”  Nationwide training of Regional NCDPC Coordinators and Training staff/HEPOs on the promotion of HL  Passing of the Anti-Tobacco Law 2004  The Philippine Coalition for the Prevention of Non-Communicable Diseases established  Scanning of NCD-related laws and policies  DOH initiated talks with commercial food establishments to offer healthier menu options to the public 2005  Training of national government agencies on DepED, DSWD, DOT, etc.) Parallel to this integrated program areHL (DILG, relevant vertical programs

on

cardiovascular disease, diabetes and cancer and tobacco control. The current framework of the DOH, FOURmula One for Health (F1), addresses the implementation of critical health interventions according to 4 pillars

13

namely, governance, service delivery, regulation and health care financing.

This

framework was designed to achieve better health outcomes, obtain a more responsive health system and a more equitable health care financing. The integrated approach towards the prevention and control non-communicable diseases follows the F1 framework.

14

World Health Organization, Global Strategy for the Prevention and Control of Non-communicable Diseases. Provisional Agenda item 12.11,

1

(Geneva: 2000)

2

World Health Organization, Preventing Chronic Diseases: A Vital Investment (Geneva: WHO, 52)

3

World Health Organization, Preventing Chronic Disease: A Vital Investment, October 23, 2008,

<www.who.int/chp/chronic_disease_report/full_report.pdf>

4

World Health Organization, Healthy Living: What is Healthy Lifestyle? October 25, 2008

5

World Health Organization. Tobacco Facts, October 23, 2008,

6

Judith Mackay and Micheal Eriksen, The Tobacco Atlas, (Geneva: 2002)

7 World

Health Organization. Tobacco Facts, October 23,2008
on October 23, 2008>

8

Ibid.

9

Ibid

10 Jha Prabhat et al, Disease Priorities in Developing Countries: Tobacco Addiction, The World Bank Group 2006, October 23, 2008

11 Ibid. p. 870

Charles W. Warren et al, Global Youth Tobacco Surveillance (GYTS), CDC January 2008, October 28, 2008

12



13

Ibid.

14 Rahmat

15

Awang, Penipuan dan Manipulasi Industri Tembakau,Pusat Racun Negara, 2008.

World Health Organization and Tim Evans et al. World Health Report 2003, (Geneva: 2003)

16 Ibid. p. 78

17

World Health Organization, WHO Report on the Global Tobacco Epidemic 2008: The MPOWER package, (Geneva: WHO,

9-10)