The smoking epidemic
 

BY Dr. Senarath Tennakoon

THE World Health Organisation (WHO) has described tobacco smoking as an epidemic. The average loss of life for someone who smokes 20 cigarettes a day is five years, and since one in four smokers die prematurely due to smoking, the loss of life for an individual may be as much as 20 years.

Tobacco smoke contains several noxious substances such as nicotine, butane, ammonia and carbon monoxide which can harm the human body.

The addictive properties of tobacco are well-known. Pulmonary tuberculosis is more common among smokers than among non-smokers.

Tobacco causes lung cancer, coronary heart disease, chronic lung disease (bronchitis and emphysema), gingivitis and early extraction of teeth, Buerger's disease (diseases of the peripheral blood vessels) and kidney disease.

Pregnant mothers who inhale cigarette smoke are facing the threat of causing lung illness of their babies and these babies do not grow well-stunting and low birth weight.

Surveys show that smokers find it difficult to give up smoking, 70 per cent want to stop smoking. The benefits of giving up smoking are well-known.

Within 12 hours of quitting smoking, the body will start its healing process. The level of carbon monoxide and nicotine will show a decline and the heart and lungs begin to function normally. In a few days the smoker's abnormal sense of taste and smell will return to normal and the smoker's cough disappears.

The previous smoker will find it easy to climb up a stair case now. Economic and family life benefits are immeasurable, if the breadwinner gives up smoking. In Sri Lanka, it has been found that annually around a sum of Rupees 17 million is being wasted on smoking and is a major cause for poverty (Olcott Goonasekara, 1997).

The vulnerable groups are the adolescent and the youth, the lonely aged, the unemployed, those under stressful situations, bad company, family problems and those who receive cigarettes as incentives for efficient work performance.

Some have a false sense of well-being and of an stimulatory effect of a smoke when starting a work, taking food or drink and meeting a friend.

There are established approaches for quitting the harmful practice of smoking. List all reasons why one wants to give up. Set a target date to quit - your or your child's birthday.

Begin with an alternative like nicotine chewing gum. Cut down the number of cigarettes smoked/take fewer puffs/inhale less. Join non-smoking social groups. Seek medical advice.

The association between cigarette smoking and lung cancer, cardiovascular disease, and some other conditions has been amply demonstrated and campaigns aimed at persuading people to stop smoking have shown benefits (Richard Farmer et al 1991).

Many studies show that the mortality and morbidity of ex-smokers is less that of those who continue to smoke. A randomised controlled trial of anti-smoking advice to 1,445 male smokers, aged 40-49 years, at high risk of developing cardiovascular disease in 1968 continued for over 10 years.

In this study the intervention group were given individual advice on the relationship between smoking and health. Those who wished to quit smoking were given support and were encouraged for over 12 months. The other control group members were not given specific advice.

Deaths in the two groups were monitored. After one year the reported cigarette consumption in the intervention group was found to be one quarter of that of the control group and over 10 years the reduction was 53 per cent.

The intervention group experienced fewer respiratory symptoms and less loss of ventilatory function. Their mortality from heart disease was 18 per cent less than that of the controls, and for lung cancer it was 23 per cent lower.

The study concluded that the policy encouraging smokers to give up the habit was worthwhile and should not be changed (Ross et al 1982).

In Japan, where the economy is on a strong footing, tobacco smoking seems to continue unabated. The Finance Ministry holds a 67 per cent stake in Japan Tobacco Inc (JT) and more than 2.5 percent of total tax revenue is accrued from cigarette sales. Cigarettes are cheap in Japan.

The anti-smoking health messages are not so powerful unlike in other parts of Europe. About a third of all Japanese adults smoke, young women and teenagers are joining the smoking population in alarming numbers. Almost 25 per cent of women in their 20s smoke and one in four of high school pupils do smoke.

In 1998 six Japanese men, aged 60-80 years filed a case with the Tokyo District Court, against the government and the Japanese Tobacco Inc, seeking a 60 million yen (US$ 553,000) damage. They said that JT had knowingly sold them cigarettes without properly informing them of the health risks. But they lost the case.

The judge Kikuo Asaka declared in his judgement, 'Nicotine is addictive, but it is not enough to override the free will of each smoker. It is hard to accept that smokers cannot quit with some willpower and effort.' This judgement has caused an unpleasant feeling among the anti-smoking groups. But anti-smoking campaigns are active in Japan.

The legal smoking age is 20. Smoking areas are disappearing from public places. Smokers are on the spot fined if caught puffing in certain parts of Tokyo. Explicit health warnings covering more than 30 per cent of the cigarette packet will appear in 2005. (Justin McCurry, The Lancet (2003)).

There are three common indices of risk; absolute, relative and attributive. Absolute risk is the most basic measurement. It is the incidence of the disease amongst the people exposed to smoking.

But, this is not very useful, as it eliminates other factors that contribute to illhealth or death. Relative risk is the ratio of the incidence rate in the exposed group to that of the unexposed group and is expressed sometimes as a percentage.

Attributive risk is the difference between the incidence rates in the exposed and the non-exposed groups. The tobacco companies are aware of the vulnerable populations and their demands for smoking and they are particularly interested in knowing the details of the potential users and the unmet demands.

From the point of the smoker, it may be possible that he may not perceive the need for quitting smoking as he may perceive a disease being caused not due to smoking but due to some other cause.

Only a professional worker would be able to identify the unperceived need of a smoker. This would generate pressure for intervention. If the health services and the healthcare personnel are proactive rather than being reactive, epidemics like smoking could be effectively managed and controlled.